Basic Information
| Provider Information | |||||||||
| NPI: | 1720082555 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TATE | ||||||||
| FirstName: | GLEN | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9 | ||||||||
| Address2: | |||||||||
| City: | LAUREL FORK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 243520009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2763982292 | ||||||||
| FaxNumber: | 2763983331 | ||||||||
| Practice Location | |||||||||
| Address1: | 14558 DANVILLE PIKE | ||||||||
| Address2: | |||||||||
| City: | LAUREL FORK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 243523982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2763982292 | ||||||||
| FaxNumber: | 2763983331 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2005 | ||||||||
| LastUpdateDate: | 03/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0101034417 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 007608942 | 05 | VA | MEDICAID |