Healthcare Provider Details

I. General information

NPI: 1023074010
Provider Name (Legal Business Name): GLENN T WETZEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

848 ADAMS AVE
MEMPHIS TN
38103
US

IV. Provider business mailing address

49 N DUNLAP ST STE 345
MEMPHIS TN
38103-2802
US

V. Phone/Fax

Practice location:
  • Phone: 901-287-7337
  • Fax:
Mailing address:
  • Phone: 901-287-5092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number39312
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number39312
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License NumberD95664
License Number StateMD
# 4
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberD95664
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: