Healthcare Provider Details

I. General information

NPI: 1720023930
Provider Name (Legal Business Name): GLEN S LOVELACE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 08/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 N 1ST ST STE 260
BOISE ID
83702-6132
US

IV. Provider business mailing address

333 N 1ST ST STE 260
BOISE ID
83702-6132
US

V. Phone/Fax

Practice location:
  • Phone: 208-345-3136
  • Fax: 208-345-0984
Mailing address:
  • Phone: 208-345-3136
  • Fax: 208-345-0984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License NumberM6570
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: