MEDICARE: GLENN EDWARD BURNETT II 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	207R00000X	Internal Medicine Physician	11577A	WY

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	:	1467400747
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLENN EDWARD BURNETT II MD

Provider Business Mailing Address
First Line	:	PO BOX 428
Second Line	:
City	:	JACKSON
State	:	WY
Zip	:	83001-0428
Country	:	US
Telephone Number	:	307-733-2722
Fax Number	:	307-733-9720

Provider Business Practice Location Address
First Line	:	555 E BROADWAY AVE STE 201
Second Line	:
City	:	JACKSON
State	:	WY
Zip	:	83001-8640
Country	:	US
Telephone Number	:	307-733-7222
Fax Number	:	307-733-9720

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

Provider Enumeration Date	:	05/05/2006
Last Update Date	:	01/23/2021

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