# GLEN S LOVELACE MD PA

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1023053204
- **Authorized official:** DR. GLEN S LOVELACE MD (OWNER)
- **Authorized official phone:** (208) 345-3136

## Contact information

- **Practice address:** 333 N 1ST ST STE 260, BOISE, ID 83702-6132
- **Practice address phone:** (208) 345-3136
- **Practice address fax:** (208) 345-0984
- **Mailing address:** 333 N 1ST ST STE 260, BOISE, ID 83702-6132
- **Mailing address phone:** (208) 345-3136
- **Mailing address fax:** (208) 345-0984

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 174400000X | Specialist | M6570 | ID | Yes |

## Other

- **Enumeration date:** 06/19/2006
- **Last updated:** 06/01/2009

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 000010028711 | BLUE SHIELD GROUP NUMBER | ID |
| 01 | — | 8D608 | BLUE CROSS GROUP NUMBER | ID |