Healthcare Provider Details

I. General information

NPI: 1710996624
Provider Name (Legal Business Name): GLENN PHILLIP SCHOETTLE JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 10/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6005 PARK AVE SUITE 802
MEMPHIS TN
38119-5202
US

IV. Provider business mailing address

6005 PARK AVE SUITE 802
MEMPHIS TN
38119-5202
US

V. Phone/Fax

Practice location:
  • Phone: 901-236-0508
  • Fax: 901-682-2143
Mailing address:
  • Phone: 901-236-0508
  • Fax: 901-682-2143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberMD0000008085
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: