Provider Demographics
NPI:1811961717
Name:GLOTZBACH, RAYMOND E (MD)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:E
Last Name:GLOTZBACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1483
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1483
Mailing Address - Country:US
Mailing Address - Phone:317-663-6055
Mailing Address - Fax:317-663-6054
Practice Address - Street 1:5959 PARK AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5200
Practice Address - Country:US
Practice Address - Phone:901-765-2131
Practice Address - Fax:901-765-2064
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10333207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR110551001Medicaid
MS08177008Medicaid
TN3043912Medicaid
TN3043913Medicare PIN
AR5L099C278Medicare PIN
TN3043912Medicaid