Individual
GLENN A MANDEVILLE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1429 N 6TH ST, TERRE HAUTE, IN 47807-1037
(812) 242-3110
(812) 242-3795
Mailing address
221 S 6TH ST, TERRE HAUTE, IN 47807-4214
(812) 242-3110
(812) 242-3795
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
01041222A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000089623
ANTHEM
—
01
—
020024441
RAILROAD MCARE PALAMETTO
—
05
—
100337060
—
IN
01
—
P00834915
RAILROAD MEDICARE
IN
Enumeration date
08/29/2006
Last updated
03/14/2013
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