Provider Demographics
NPI:1154413615
Name:LOVEJOY, GLEN R (MD)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:R
Last Name:LOVEJOY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 COBB CITY RD
Mailing Address - Street 2:
Mailing Address - City:COLEBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06021-1121
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 PORTER DRIVE
Practice Address - Street 2:PORTER HOSPITAL
Practice Address - City:MIDDLEBURY
Practice Address - State:VT
Practice Address - Zip Code:05753
Practice Address - Country:US
Practice Address - Phone:802-388-4001
Practice Address - Fax:802-388-5612
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2011-01-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VT420007650207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0009688Medicaid
NY3843Medicaid
VT77V126OtherMVP
VT3843OtherBCBS
NY3843Medicaid
VT0009688Medicaid