MEDICARE: DR. GLENN E. KNOWLTON PHD

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	210	ND

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	21784	OTHER	ND	BLUECROSS/SHIELD -NO DAK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	475441026976	OTHER		PREFERRED ONE
4	61-77289	OTHER		MEDICA (UBH)
5	266S4KN	OTHER	MN	BLUE CROSS/SHIELD-MINNESO
6	HP22979	OTHER		HEALTHPARTNERS
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1063482297
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GLENN E. KNOWLTON PHD

Provider Business Mailing Address
First Line	:	1401 13TH AVE E
Second Line	:
City	:	WEST FARGO
State	:	ND
Zip	:	58078-3468
Country	:	US
Telephone Number	:	701-364-0060
Fax Number	:	701-364-0065

Provider Business Practice Location Address
First Line	:	1401 13TH AVE E
Second Line	:
City	:	WEST FARGO
State	:	ND
Zip	:	58078-3468
Country	:	US
Telephone Number	:	701-364-0060
Fax Number	:	701-364-0065

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

Provider Enumeration Date	:	01/23/2006
Last Update Date	:	01/29/2008

2101 E JEFFERSON ST PPQA MEDICARE COMPLIANCE UNT 6 WEST , KAISER PERMANENTE MID ATLANTIC PERMANENTE MEDICAL GROUP
ROCKVILLE, MD
20852-4908

Practice Phone: 301-816-6660
Practice Fax: 301-816-6308