Provider Demographics
NPI:1588658462
Name:GLASSELL, EDWIN C (MD FACG)
Entity type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:C
Last Name:GLASSELL
Suffix:
Gender:M
Credentials:MD FACG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8000 WOLF RIVER BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-1755
Mailing Address - Country:US
Mailing Address - Phone:901-747-3630
Mailing Address - Fax:615-846-4352
Practice Address - Street 1:3217 MABEL ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4022
Practice Address - Country:US
Practice Address - Phone:318-631-9121
Practice Address - Fax:318-638-6018
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA015402207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA772752OtherMEDICARE PIN
LA1316776Medicaid
LA396300YKACMedicare PIN
LA396300YTS0Medicare PIN