Provider Demographics
NPI:1831236827
Name:S. GLENN BAILEY O.D., INC.
Entity type:Organization
Organization Name:S. GLENN BAILEY O.D., INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:304-733-0809
Mailing Address - Street 1:6010 US ROUTE 60 E
Mailing Address - Street 2:
Mailing Address - City:BARBOURSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25504-1029
Mailing Address - Country:US
Mailing Address - Phone:304-733-0808
Mailing Address - Fax:304-733-4234
Practice Address - Street 1:6010 US ROUTE 60 E
Practice Address - Street 2:
Practice Address - City:BARBOURSVILLE
Practice Address - State:WV
Practice Address - Zip Code:25504-1029
Practice Address - Country:US
Practice Address - Phone:304-733-0808
Practice Address - Fax:304-733-4234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV717-OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0150705001Medicaid
WVT65165Medicare UPIN
WV9281721Medicare ID - Type Unspecified