Provider Demographics
NPI:1730500141
Name:GLENN, GEORGE FLEMING (CCP)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:FLEMING
Last Name:GLENN
Suffix:
Gender:M
Credentials:CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1812 PARTRIDGE PL
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-5512
Mailing Address - Country:US
Mailing Address - Phone:314-443-1024
Mailing Address - Fax:314-656-1535
Practice Address - Street 1:7220 N LINDBERGH BLVD
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-2019
Practice Address - Country:US
Practice Address - Phone:314-838-8000
Practice Address - Fax:314-838-8304
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-02
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO199140713242T00000X
IL214.000313242T00000X
WI125-18242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist