Healthcare Provider Details

I. General information

NPI: 1003841537
Provider Name (Legal Business Name): GLEN CARLSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 NW MYHRE RD
SILVERDALE WA
98383-7663
US

IV. Provider business mailing address

PO BOX 920135
DALLAS TX
75392-0135
US

V. Phone/Fax

Practice location:
  • Phone: 564-240-1000
  • Fax:
Mailing address:
  • Phone: 877-346-2211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD00034699
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: