Provider Demographics
NPI:1023141025
Name:BEASLEY, GLENN A (MD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:A
Last Name:BEASLEY
Suffix:
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 1:2158 NORTHGATE PARK LN
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37415-6957
Mailing Address - Country:US
Mailing Address - Phone:423-870-2030
Mailing Address - Fax:423-875-6405
Practice Address - Street 1:2158 NORTHGATE PARK LN
Practice Address - Street 2:SUITE 104
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37415-6957
Practice Address - Country:US
Practice Address - Phone:423-870-2030
Practice Address - Fax:423-875-6405
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000020673207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3053865Medicaid
TNC68858Medicare UPIN
TN3720420Medicare PIN
TN3053863Medicare PIN