MEDICARE: DR. GLEN PRIESTER DAVIS 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	2084P0800X	Psychiatry Physician	239049	NY
2	282N00000X	General Acute Care Hospital	239049	NY

General Provider Information

NPI Number	:	1912128356
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GLEN PRIESTER DAVIS M.D.

Provider Business Mailing Address
First Line	:	198 E 121ST ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10035-3523
Country	:	US
Telephone Number	:	212-803-2727
Fax Number	:	646-335-0667

Provider Business Practice Location Address
First Line	:	198 E 121ST ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10035-3523
Country	:	US
Telephone Number	:	212-803-2727
Fax Number	:	646-335-0667

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

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	03/12/2014

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