Healthcare Provider Details

I. General information

NPI: 1669459616
Provider Name (Legal Business Name): MARILYN K. GLASER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 11/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 ALTA DRIVE
ALDERSON WV
24910-0680
US

IV. Provider business mailing address

PO BOX 1049
LEWISBURG WV
24901-4049
US

V. Phone/Fax

Practice location:
  • Phone: 304-445-7940
  • Fax: 304-445-2437
Mailing address:
  • Phone: 304-645-4043
  • Fax: 304-645-4713

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number15169
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: