Provider Demographics
NPI:1104821222
Name:MCPHILLIPS, GLENN STEPHEN (DPM)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:STEPHEN
Last Name:MCPHILLIPS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 OFFICE PARK CIR
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:AL
Mailing Address - Zip Code:36701-6506
Mailing Address - Country:US
Mailing Address - Phone:334-872-5636
Mailing Address - Fax:334-872-5199
Practice Address - Street 1:6 OFFICE PARK CIR
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:AL
Practice Address - Zip Code:36701-6506
Practice Address - Country:US
Practice Address - Phone:334-872-5636
Practice Address - Fax:334-872-5199
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL248213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALMC051552783Medicaid
U84882Medicare UPIN
ALMC051552783Medicaid
AL5227530001Medicare NSC