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NPI Code Detail

MEDICARE: DR. JACK J 'BUDDY' GLISSON M.D.

MEDICARE: DR. JACK J 'BUDDY' GLISSON M.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207R00000XInternal Medicine Physician21707TN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1184611923
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. JACK J 'BUDDY' GLISSON M.D.
Provider Business Mailing Address
First Line : 130 E LOCUST ST
Second Line :
City : DRESDEN
State : TN
Zip : 38225-1467
Country : US
Telephone Number : 731-364-3196
Fax Number : 731-364-5359
Provider Business Practice Location Address
First Line : 130 E LOCUST ST
Second Line :
City : DRESDEN
State : TN
Zip : 38225-1467
Country : US
Telephone Number : 731-364-3196
Fax Number : 731-364-5359
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/05/2005
Last Update Date : 07/08/2007

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