Provider Demographics
NPI:1982067179
Name:GLEN HALVORSON MD PLLC
Entity Type:Organization
Organization Name:GLEN HALVORSON MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:HALVORSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-795-3649
Mailing Address - Street 1:4550 E BELL RD
Mailing Address - Street 2:STE 150
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-9306
Mailing Address - Country:US
Mailing Address - Phone:602-795-3674
Mailing Address - Fax:602-795-3996
Practice Address - Street 1:4550 E BELL RD
Practice Address - Street 2:STE 150
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-9306
Practice Address - Country:US
Practice Address - Phone:602-795-3649
Practice Address - Fax:602-795-3996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-04
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13423208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ13423OtherSTATE LICENSE
AZ235780Medicaid
AZ235780Medicaid