NPIMap

Organization Active NPI

Glen S Lovelace MD PA

  • Specialist
  • Boise, ID
National Provider Identifier
1023053204
Registry record updated Jun 1, 2009
On this page

Key facts

NPPES NPI Registry
Primary specialty
SpecialistTaxonomy code 174400000X
License
M6570 Issued in ID
Legal business name
GLEN S LOVELACE MD PA
Practice address
333 N 1St St Ste 260
Boise, ID 83702-6132
Phone
(208) 345-3136
Fax
(208) 345-0984
NPI assigned
Jun 19, 2006
Last updated
Jun 1, 2009By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 1, 2009

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Glen S Lovelace, MDNPI 1720023930
Title
Owner
Phone
(208) 345-3136

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Specialist 174400000X M6570 ID Primary

Addresses

Primary practice location

333 N 1St St Ste 260
Boise, ID 83702-6132

Mailing address

333 N 1St St Ste 260
Boise, ID 83702-6132
Phone (208) 345-3136

Other identifiers 2

IdentifierTypeStateIssuer
8D608OtherIDBLUE CROSS GROUP NUMBER
000010028711OtherIDBLUE SHIELD GROUP NUMBER

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ID

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20110103000329 ID Part B Supplier - Clinic/Group Practice 7416145628 Receives reassigned benefits from 4 practitioners
Practice locations: Boise, ID

National Provider Directory

National Provider Directory

Locations

333 N 1st St
Ste 260
Boise, ID 83702
Phone (208) 345-3136

Practitioners & affiliated clinicians

Practitioners 8

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1150675200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1243814400000",
    "number": "1023053204",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "333 N 1ST ST STE 260",
            "city": "BOISE",
            "state": "ID",
            "postal_code": "837026132",
            "telephone_number": "208-345-3136",
            "fax_number": "208-345-0984"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "333 N 1ST ST STE 260",
            "city": "BOISE",
            "state": "ID",
            "postal_code": "837026132",
            "telephone_number": "208-345-3136",
            "fax_number": "208-345-0984"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GLEN S LOVELACE MD PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-19",
        "last_updated": "2009-06-01",
        "status": "A",
        "authorized_official_last_name": "LOVELACE",
        "authorized_official_first_name": "GLEN",
        "authorized_official_middle_name": "S",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "208-345-3136",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "",
            "desc": "Specialist",
            "state": "ID",
            "license": "M6570",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS GROUP NUMBER",
            "identifier": "8D608",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE SHIELD GROUP NUMBER",
            "identifier": "000010028711",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Boise, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 1, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.