Basic Information
| Provider Information | |||||||||
| NPI: | 1457315533 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLENN | ||||||||
| FirstName: | CHRIS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 140349 | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995140349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077927975 | ||||||||
| FaxNumber: | 9077927901 | ||||||||
| Practice Location | |||||||||
| Address1: | 2741 DEBARR RD | ||||||||
| Address2: | SUITE 401 | ||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995082961 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077927975 | ||||||||
| FaxNumber: | 9077927901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2006 | ||||||||
| LastUpdateDate: | 09/24/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | G79975 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 8122 | AK | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | 8122 | AK | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00G799750 | 01 | CA | BLUE SHIELD OF CA | OTHER | 00G799750 | 05 | CA | MEDICAID | 1457315533 | 05 | CA | MEDICAID |