Provider Demographics
NPI:1316995749
Name:HATCHER, GLEN H (MD)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:H
Last Name:HATCHER
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 1:1301 SUNSET DR
Mailing Address - Street 2:STE 3
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-7906
Mailing Address - Country:US
Mailing Address - Phone:423-926-4966
Mailing Address - Fax:423-926-1823
Practice Address - Street 1:1301 SUNSET DR
Practice Address - Street 2:STE 3
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-7906
Practice Address - Country:US
Practice Address - Phone:423-926-4966
Practice Address - Fax:423-926-1823
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN263282085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3116310OtherBCBS
NC89063JGOtherNORTH CAROLINA MEDICAID
TN385719Medicaid
KY64017106OtherKENTUCKY MEDICAID
VA7222211OtherVIRGINIA MEDICAID
TN3116310OtherBCBS
TN385719Medicare ID - Type Unspecified