Healthcare Provider Details

I. General information

NPI: 1366408759
Provider Name (Legal Business Name): GLEN L LOVEDAY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 07/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 EAST JULIA
WYNNE AR
72396
US

IV. Provider business mailing address

623 N 9TH STREET PO BOX 497
AUGUSTA AR
72006
US

V. Phone/Fax

Practice location:
  • Phone: 870-238-0377
  • Fax: 870-238-5583
Mailing address:
  • Phone: 870-347-3300
  • Fax: 870-347-3492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberE3916
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: