Provider Demographics
NPI:1831199835
Name:SCHWENK, GLENN RUDOLPH JR (MD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:RUDOLPH
Last Name:SCHWENK
Suffix:JR
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 1:12188 A NORTH MERIDIAN ST
Mailing Address - Street 2:SUITE 375
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-4578
Mailing Address - Country:US
Mailing Address - Phone:317-926-1056
Mailing Address - Fax:317-579-0476
Practice Address - Street 1:12188 A NORTH MERIDIAN ST
Practice Address - Street 2:SUITE 375
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-4578
Practice Address - Country:US
Practice Address - Phone:317-926-1056
Practice Address - Fax:317-579-0476
Is Sole Proprietor?:No
Enumeration Date:2005-08-01
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030262A207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100378730Medicaid
IN000000231409OtherBCBS
505530AMedicare ID - Type Unspecified
E29025Medicare UPIN
IN000000231409OtherBCBS