Basic Information
| Provider Information | |||||||||
| NPI: | 1902866080 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARPER | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | ANTHONY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1340 HAL GREER BLVD | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257013804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045262200 | ||||||||
| FaxNumber: | 3043991507 | ||||||||
| Practice Location | |||||||||
| Address1: | 1340 HAL GREER BLVD | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257013804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045262200 | ||||||||
| FaxNumber: | 3043991507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 02/16/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 18732 | WV | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | 18732 | WV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64433402 | 05 | KY | MEDICAID | 1902866080 | 05 | WV | MEDICAID | Q053993 | 05 | TN | MEDICAID | 2215294 | 05 | OH | MEDICAID | P00080663 | 01 | WV | MEDICARE-RR PROVIDER NUMBER | OTHER |