Provider Demographics
NPI:1811181308
Name:GLISSON, COLLEEN ELIZABETH (MD)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:ELIZABETH
Last Name:GLISSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12639 OLD TESSON RD
Mailing Address - Street 2:SUITE 115
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2786
Mailing Address - Country:US
Mailing Address - Phone:314-849-0311
Mailing Address - Fax:
Practice Address - Street 1:845 N NEW BALLAS CT
Practice Address - Street 2:SUITE 200
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7134
Practice Address - Country:US
Practice Address - Phone:314-983-4700
Practice Address - Fax:314-692-9862
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010010436207X00000X, 207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1811181308Medicaid
MO122950035Medicare PIN