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General NPI Number Information
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NPI Number | 1174522577
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Entity Type | Individual
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Provider Name | JON RYAN GLASS M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/18/2005
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Last Update Date | 01/17/2014
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Provider Practice Location Address
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Address Line | 1111 MEDICAL CENTER BLVD S-650
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City | MARRERO
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State | LA
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Zip | 70072-3151
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Country | US
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Telephone | 504-934-8100
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Fax | 504-934-8102
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Provider Business Mailing Address
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Address Line | 1111 MEDICAL CENTER BLVD S-650
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City | MARRERO
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State | LA
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Zip | 70072-3151
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Country | US
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Telephone | 504-934-8100
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Fax | 504-934-8102
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | 025041
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License Number State | LA
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