Healthcare Provider Details

I. General information

NPI: 1316108764
Provider Name (Legal Business Name): GLENN EDWARD HURST M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2008
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 RIDGE ST STE 201
COUNCIL BLUFFS IA
51503-4643
US

IV. Provider business mailing address

PO BOX 306
MINDEN IA
51553-0306
US

V. Phone/Fax

Practice location:
  • Phone: 712-322-5899
  • Fax:
Mailing address:
  • Phone: 712-407-2086
  • Fax: 712-407-2087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5360
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: