MEDICARE: JORGE N GLASS MD

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	207RC0200X	Critical Care Medicine (Internal Medicine) Physician	ME143190	FL
2	207RP1001X	Pulmonary Disease Physician	50609	TN
3	207RP1001X	Pulmonary Disease Physician	66607	GA
4	207RP1001X	Pulmonary Disease Physician	ME143190	FL

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	:	1235107681
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORGE N GLASS MD

Provider Business Mailing Address
First Line	:	PO BOX 2462
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84110-2462
Country	:	US
Telephone Number	:	904-202-1032
Fax Number	:	904-376-4107

Provider Business Practice Location Address
First Line	:	1348 S 18TH ST STE 210
Second Line	:
City	:	FERNANDINA BEACH
State	:	FL
Zip	:	32034-4785
Country	:	US
Telephone Number	:	904-261-9108
Fax Number	:	904-261-9911

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

Provider Enumeration Date	:	03/10/2006
Last Update Date	:	02/12/2020

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Directions to “ JORGE N GLASS MD” Practice Location

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