Basic Information
| Provider Information | |||||||||
| NPI: | 1760488191 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GLASSER | ||||||||
| FirstName: | JACK | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 MARYLAND FARMS | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153737600 | ||||||||
| FaxNumber: | 8663461426 | ||||||||
| Practice Location | |||||||||
| Address1: | 1325 ANDREA ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421045852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2709013454 | ||||||||
| FaxNumber: | 2709013458 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2005 | ||||||||
| LastUpdateDate: | 10/10/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 19937 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64199375 | 05 | KY | MEDICAID | 080155383 | 01 | KY | RAILROAD MEDICARE | OTHER | 50006908 | 01 | KY | PASSPORT | OTHER | 000000065732 | 01 | KY | ANTHEM | OTHER |