Basic Information
| Provider Information | |||||||||
| NPI: | 1457779266 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GLENN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | MOLLOY | ||||||||
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| NameSuffix: | III | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 UNIVERSITY OF NEW MEXICO | ||||||||
| Address2: | MSC 10 5610 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052726487 | ||||||||
| FaxNumber: | 5052724156 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 S PARK ST | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537151830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082516100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2014 | ||||||||
| LastUpdateDate: | 11/17/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 18346 | WI | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1457779266 | 05 | WI | MEDICAID |