Provider Demographics
NPI:1336535053
Name:GLOVER, WENDELL (MD)
Entity type:Individual
Prefix:DR
First Name:WENDELL
Middle Name:
Last Name:GLOVER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:WENDY
Other - Middle Name:
Other - Last Name:GLOVER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:11 PROFESSIONAL PKWY
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-4114
Mailing Address - Country:US
Mailing Address - Phone:601-856-2460
Mailing Address - Fax:601-856-5363
Practice Address - Street 1:11 PROFESSIONAL PKWY
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-4114
Practice Address - Country:US
Practice Address - Phone:601-856-2460
Practice Address - Fax:601-856-5363
Is Sole Proprietor?:No
Enumeration Date:2015-04-09
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11734171W00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSB2825WS4MSMedicaid