MEDICARE: DR. GREGORY LYON GLOWACKI 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	208000000X	Pediatrics Physician	015143	LA
2	207P00000X	Emergency Medicine Physician	MD.015143	LA

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	:	1710917414
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREGORY LYON GLOWACKI M.D.

Provider Business Mailing Address
First Line	:	PO BOX 53247
Second Line	:
City	:	LAFAYETTE
State	:	LA
Zip	:	70505-3247
Country	:	US
Telephone Number	:	337-289-8780
Fax Number	:	337-571-0010

Provider Business Practice Location Address
First Line	:	1555 GARY DR STE A
Second Line	:
City	:	BREAUX BRIDGE
State	:	LA
Zip	:	70517-3448
Country	:	US
Telephone Number	:	337-909-2474
Fax Number	:	337-909-2479

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

Provider Enumeration Date	:	07/05/2006
Last Update Date	:	12/09/2020

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