Provider Demographics
NPI:1316947450
Name:ARCHIBALD, GLENN O (MD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:O
Last Name:ARCHIBALD
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 1:3181 BRADFORD PL
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-4603
Mailing Address - Country:US
Mailing Address - Phone:205-478-8256
Mailing Address - Fax:205-448-1187
Practice Address - Street 1:801 NOBLE ST STE 400
Practice Address - Street 2:
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36201-5698
Practice Address - Country:US
Practice Address - Phone:256-294-1727
Practice Address - Fax:205-448-1187
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL160432084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL16043OtherMEDICAL LICENSE
AL051500571Medicaid
ALE53022AMedicare UPIN
ALI115Medicare PIN