Provider Demographics
NPI:1023053204
Name:GLEN S LOVELACE MD PA
Entity type:Organization
Organization Name:GLEN S LOVELACE MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:S
Authorized Official - Last Name:LOVELACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-345-3136
Mailing Address - Street 1:333 N 1ST ST STE 260
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6132
Mailing Address - Country:US
Mailing Address - Phone:208-345-3136
Mailing Address - Fax:208-345-0984
Practice Address - Street 1:333 N 1ST ST STE 260
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6132
Practice Address - Country:US
Practice Address - Phone:208-345-3136
Practice Address - Fax:208-345-0984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6570174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8D608OtherBLUE CROSS GROUP NUMBER
ID000010028711OtherBLUE SHIELD GROUP NUMBER
ID000010028711OtherBLUE SHIELD GROUP NUMBER