Provider Demographics
NPI:1124168406
Name:DAVIS, GLENN SCOTT (MD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:SCOTT
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-886-9370
Mailing Address - Fax:740-446-5153
Practice Address - Street 1:98 STATE ST
Practice Address - Street 2:
Practice Address - City:PROCTORVILLE
Practice Address - State:OH
Practice Address - Zip Code:45669-8163
Practice Address - Country:US
Practice Address - Phone:740-886-9403
Practice Address - Fax:740-446-5153
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350-72747207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1073272OtherBWC
OH000000189349OtherANTHEM
OH000000241476OtherOH MEDICAID - UNISON
110217004OtherRAILROAD MEDICARE
OH2056840OtherOH MEDICAID MOLINA
WV3810012072Medicaid
OH2056840Medicaid
OH000000241476OtherOH MEDICAID - UNISON
OH2056840Medicaid