Basic Information
| Provider Information | |||||||||
| NPI: | 1134218779 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHEELESS | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | STEPHEN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4780 N JOSEY LN | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750104615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724921334 | ||||||||
| FaxNumber: | 9724925174 | ||||||||
| Practice Location | |||||||||
| Address1: | 4780 N JOSEY LN | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750104615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724921334 | ||||||||
| FaxNumber: | 9724925174 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 05/22/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | G0280 | TX | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0005X | G0280 | TX | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 6484850003 | 01 | TX | MEDICARE NSC - EFFECT 02/01/2011 | OTHER | 8B7873 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 8CR163 | 01 | TX | BCBS TX 02/01/2011 | OTHER | P00935338 | 01 | TX | RAILROAD MEDICARE | OTHER | TXB126769 | 01 | TX | MEDICARE PART B - EFFECT. 4-20-11 | OTHER | 123405606 | 05 | TX | MEDICAID |