Basic Information
| Provider Information | |||||||||
| NPI: | 1720169386 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOREHEAD | ||||||||
| FirstName: | GLEN | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 51753 EL DORADO DR | ||||||||
| Address2: | |||||||||
| City: | LA QUINTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922539034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7606192309 | ||||||||
| FaxNumber: | 8664280708 | ||||||||
| Practice Location | |||||||||
| Address1: | 1180 N. INDIAN CANYON DR. | ||||||||
| Address2: | E218 | ||||||||
| City: | PALM SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922624800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7604164800 | ||||||||
| FaxNumber: | 7702291518 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 01/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 31076 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 000447433A | 05 | GA | MEDICAID | 000447433C | 05 | GA | MEDICAID |