=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114094737
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GLEN RONALD BAILEY MPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3090 E GENTRY WAY STE 250
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642-3501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-888-0044
-----------------------------------------------------
Fax | 208-888-2211
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3090 E GENTRY WAY STE 250
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642-3501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-888-0044
-----------------------------------------------------
Fax | 208-888-2211
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT2112
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------