MEDICARE: DR. GLENN A. BEASLEY M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207QS0010X	Sports Medicine (Family Medicine) Physician	MD0000020673	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023141025
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GLENN A. BEASLEY M.D.

Provider Business Mailing Address
First Line	:	2158 NORTHGATE PARK LN
Second Line	:	SUITE 104
City	:	CHATTANOOGA
State	:	TN
Zip	:	37415-6957
Country	:	US
Telephone Number	:	423-870-2030
Fax Number	:	423-875-6405

Provider Business Practice Location Address
First Line	:	2158 NORTHGATE PARK LN
Second Line	:	SUITE 104
City	:	CHATTANOOGA
State	:	TN
Zip	:	37415-6957
Country	:	US
Telephone Number	:	423-870-2030
Fax Number	:	423-875-6405

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/13/2007
Last Update Date	:	03/13/2008

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