Provider Demographics
NPI:1699755975
Name:BEDSOLE, GLENN DAVID (MD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:DAVID
Last Name:BEDSOLE
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:PO BOX 242848
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36124-2848
Mailing Address - Country:US
Mailing Address - Phone:334-270-9914
Mailing Address - Fax:
Practice Address - Street 1:1801 PINE ST
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-0165
Practice Address - Country:US
Practice Address - Phone:334-293-8138
Practice Address - Fax:334-293-8134
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL7601207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL630979663OtherCHAMPUS/TRICARE
AL630979663OtherUHC
AL51018188OtherBC/BS
AL000018188Medicaid
AL000052096Medicare ID - Type Unspecified
AL630979663OtherUHC
AL000052100Medicare ID - Type Unspecified
AL000046498Medicare ID - Type Unspecified
000055382Medicare ID - Type Unspecified
AL051550178Medicare ID - Type Unspecified
AL630979663OtherCHAMPUS/TRICARE
AL000052101Medicare ID - Type Unspecified