Healthcare Provider Details

I. General information

NPI: 1588728596
Provider Name (Legal Business Name): GLENN MICHAEL SHIPLEY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 05/23/2022
Certification Date: 05/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 N UNIVERSITY AVE
LUBBOCK TX
79415-1734
US

IV. Provider business mailing address

701 W 51ST ST
AUSTIN TX
78751-2312
US

V. Phone/Fax

Practice location:
  • Phone: 806-741-3609
  • Fax: 806-741-3604
Mailing address:
  • Phone: 512-438-3086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number058643
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2083C0008X
TaxonomyClinical Informatics Physician
License NumberJ3607
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: