Provider Demographics
NPI:1194740373
Name:ROBERSON, GLENN
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:ROBERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 6TH AVE S
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35233-1801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1717 6TH AVE S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-1801
Practice Address - Country:US
Practice Address - Phone:800-822-8816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL230772085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL300115540OtherRAILROAD MEDICARE
AL009979470Medicaid
MS124433OtherMISSISSIPPI MEDICAID
ALB75729OtherVIVA
AL000060981Medicaid
AL010033CB75739OtherSECTION 1011
AL051505994OtherBLUE CROSS
AL000060981OtherBLUE CROSS
AL051511508OtherBLUE CROSS
AL051505994OtherBLUE CROSS