Basic Information
| Provider Information | |||||||||
| NPI: | 1942318795 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANDEVILLE | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 221 S 6TH ST | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478074214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122423110 | ||||||||
| FaxNumber: | 8122423795 | ||||||||
| Practice Location | |||||||||
| Address1: | 1429 N 6TH ST | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478071037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122423110 | ||||||||
| FaxNumber: | 8122423795 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 03/14/2013 | ||||||||
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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 | 208600000X | 01041222A | IN | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 020024441 | 01 | RAILROAD MCARE PALAMETTO | OTHER | 100337060 | 05 | IN | MEDICAID | P00834915 | 01 | IN | RAILROAD MEDICARE | OTHER | 000000089623 | 01 | ANTHEM | OTHER |