Healthcare Provider Details

I. General information

NPI: 1366447955
Provider Name (Legal Business Name): CONSTANCE LYNN GLASS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13250 HAZEL DELL PKWY STE 103
CARMEL IN
46033-8527
US

IV. Provider business mailing address

13250 HAZEL DELL PKWY STE 103
CARMEL IN
46033-8527
US

V. Phone/Fax

Practice location:
  • Phone: 317-843-9475
  • Fax: 317-843-9476
Mailing address:
  • Phone: 317-843-9475
  • Fax: 317-843-9476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number01045216A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: