Basic Information
| Provider Information | |||||||||
| NPI: | 1821061268 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLISSON | ||||||||
| FirstName: | SHAWN | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 315 E BROADWAY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402023700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026292500 | ||||||||
| FaxNumber: | 5026292055 | ||||||||
| Practice Location | |||||||||
| Address1: | 676 S FLOYD ST FL 2 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026292500 | ||||||||
| FaxNumber: | 5026292055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 11/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 01042659A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | 29701 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 830005455 | 01 | RAILROAD MEDICARE | OTHER | 000000051749 | 01 | KY | ANTHEM | OTHER | 200034300A | 05 | IN | MEDICAID | 1068275 | 01 | KY | PASSPORT | OTHER | 64297013 | 05 | KY | MEDICAID |