Basic Information
| Provider Information | |||||||||
| NPI: | 1689620536 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GLAUDE | ||||||||
| FirstName: | DENNIS | ||||||||
| MiddleName: | LEO | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 2564 | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787465644 | ||||||||
| FaxNumber: | 4787454849 | ||||||||
| Practice Location | |||||||||
| Address1: | 380 HOSPITAL DR. | ||||||||
| Address2: | SUITE 410 | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312178014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062824200 | ||||||||
| FaxNumber: | 7068868045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 02/07/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN078329 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 580628385 | 01 | GA | TRICARE | OTHER | 000547797F | 05 | GA | MEDICAID | P00257335 | 01 | GA | MEDICARE RAILROAD | OTHER | 003105057A | 05 | GA | MEDICAID |