Provider Demographics
NPI:1881649564
Name:GLENN, LISA BIRY (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:BIRY
Last Name:GLENN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 W 51ST ST
Mailing Address - Street 2:MC W580
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78751-2312
Mailing Address - Country:US
Mailing Address - Phone:512-438-3530
Mailing Address - Fax:
Practice Address - Street 1:701 W 51ST ST
Practice Address - Street 2:MC W580
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78751-2312
Practice Address - Country:US
Practice Address - Phone:512-438-3530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH4350207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX139329010Medicaid
TX2046906-01Medicaid
TX81637JMedicare PIN
TX139329010Medicaid