MEDICARE: GLENN L NUDELMAN 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	174400000X	Specialist	14122	AZ
2	207R00000X	Internal Medicine Physician	AN14122	AZ
3	207R00000X	Internal Medicine Physician	14122	AZ

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	110044210	OTHER	AZ	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1346242427
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLENN L NUDELMAN M.D.

Provider Business Mailing Address
First Line	:	2191 CHIP DR
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86406-7645
Country	:	US
Telephone Number	:	928-486-4387
Fax Number	:	928-302-3515

Provider Business Practice Location Address
First Line	:	2191 CHIP DR
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86406-7645
Country	:	US
Telephone Number	:	928-486-4387
Fax Number	:	928-302-3515

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

Provider Enumeration Date	:	08/10/2005
Last Update Date	:	07/29/2022

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