Individual
GLEN DAVID SHAPIRO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
513 N MAIN ST, HAILEY, ID 83333
(877) 754-6330
(877) 993-1515
Mailing address
1420 N 2ND AVE, HAILEY, ID 83333
(877) 754-6330
(877) 993-1515
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
Primary
M9172
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0001364855
—
ID
01
—
100000294843
REGENCE
ID
01
—
11289122
PTAN
ID
01
—
B6493
BCID
ID
01
—
P00247850
RAILROAD MEDICARE
ID
Enumeration date
02/19/2007
Last updated
05/23/2012
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