Provider Demographics
NPI:1255450649
Name:WEYHRICH, GLENN HOWARD (MD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:HOWARD
Last Name:WEYHRICH
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 1:222 N 2ND ST STE 206
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6130
Mailing Address - Country:US
Mailing Address - Phone:208-342-2516
Mailing Address - Fax:208-342-1661
Practice Address - Street 1:222 N 2ND ST STE 206
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6130
Practice Address - Country:US
Practice Address - Phone:208-342-2516
Practice Address - Fax:208-342-1661
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILM3119207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDM3119OtherIDAHO STATE LICENSE
ID01602650631OtherAMA MEMBERSHIP
ID13D0521509OtherCLIA LAB ID NUMBER
ID002523800Medicaid
IDMD1637OtherIDAHO CONTROLLED SUBSTANC
ID000010000709OtherREGENCE BLUE SHIELD OF ID
OR140277OtherOMAP OREGON MEDICAID
ID50120OtherBLUE CROSS OF IDAHO
ID50120OtherBLUE CROSS OF IDAHO
ID000010000709OtherREGENCE BLUE SHIELD OF ID
ID002523800Medicaid