Basic Information
| Provider Information | |||||||||
| NPI: | 1407887979 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GLASER | ||||||||
| FirstName: | JOSEPHINE | ||||||||
| MiddleName: | LEE AGUHOB | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3721 S GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631183405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143280144 | ||||||||
| FaxNumber: | 3147883021 | ||||||||
| Practice Location | |||||||||
| Address1: | 3721 S GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631183405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143280144 | ||||||||
| FaxNumber: | 3147883021 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 01/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2015005800 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4000501 | 01 | KY | MEDICARE LAB GROUP | OTHER | CB5773 | 01 | KY | RR MEDICARE GROUP | OTHER | 080150788 | 01 | KY | RR MEDICARE PIN NO | OTHER | 37903705 | 01 | KY | MEDICAID LAB GROUP | OTHER | 64341589 | 05 | KY | MEDICAID |