MEDICARE: RONNIE GLENN

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	172A00000X	Driver	RT505487	OH

General Provider Information

NPI Number	:	1194311654
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RONNIE GLENN

Provider Business Mailing Address
First Line	:	6497 JACKSON PIKE
Second Line	:
City	:	GROVE CITY
State	:	OH
Zip	:	43123-9195
Country	:	US
Telephone Number	:	614-402-5194
Fax Number	:

Provider Business Practice Location Address
First Line	:	6497 JACKSON PIKE
Second Line	:
City	:	GROVE CITY
State	:	OH
Zip	:	43123-9195
Country	:	US
Telephone Number	:	614-402-5194
Fax Number	:

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

Provider Enumeration Date	:	12/17/2020
Last Update Date	:	12/17/2020

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