Basic Information
Provider Information | |||||||||
NPI: | 1194820852 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GLASS | ||||||||
FirstName: | JUSTIN | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 777 N RAYMOND ST | ||||||||
Address2: |   | ||||||||
City: | BOISE | ||||||||
State: | ID | ||||||||
PostalCode: | 837049251 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2083676030 | ||||||||
FaxNumber: | 2083227018 | ||||||||
Practice Location | |||||||||
Address1: | 777 N RAYMOND ST | ||||||||
Address2: |   | ||||||||
City: | BOISE | ||||||||
State: | ID | ||||||||
PostalCode: | 837049251 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2083676030 | ||||||||
FaxNumber: | 2083227018 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/14/2006 | ||||||||
LastUpdateDate: | 07/22/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 56066 | GA | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | M-10405 | ID | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 8HD081 | 01 |   | SANOSTEE MEDICARE PIN | OTHER | 8HZ07C | 01 |   | NNMC MEDICARE PIN | OTHER | 1194820852 | 05 | NM |   | MEDICAID | 565179 | 05 | AZ |   | MEDICAID | 8HD082 | 01 |   | TOADALENA MEDICARE PIN | OTHER | 42701279 | 05 | CO |   | MEDICAID | 808154100 | 05 | ID |   | MEDICAID | 807782300 | 05 | ID |   | MEDICAID |