Glenn Zeidman, DO
Individual provider Active NPI Family Medicine Physician · McComb, MS
NPI 1023067360 · NPPES record last updated Jul 23, 2012
Key facts
- NPI
- 1023067360
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Family Medicine Physician 207Q00000X
- License
- 18759 (MS)
- Practice address
- 1126 Country Club Rd
McComb, MS 39648-5952 - Phone
- (601) 250-0139
- Fax
- (601) 250-0139
- NPI assigned
- May 5, 2006
- Sex
- Male
- Sole proprietor
- Yes
Organizations & group practices 4
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MS
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20050202000948 | MS | Practitioner - Family Practice | 5294786687 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Osteopathy, Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 18759 | MS | MD | Family Medicine Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Zwound Care | Family Medicine | Current |
Accepting new patients |
| Mississippi Commcare Corporation a Non Profit Corporation | Past | Accepting new patients | |
| Brookhaven Ms Opco LLC | Past | Accepting new patients | |
| CSC Medical, LLC | Past | Accepting new patients |
Locations
1065 E Broad St
Monticello, MS 39654
Phone (601) 249-1350
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 18759 | MS | Yes |
Addresses
Primary practice location
1126 Country Club Rd
McComb, MS 39648-5952
Mailing address
1126 Country Club Rd
McComb, MS 39648-5952
Phone (601) 250-0139
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 00433021 | Medicaid | MS |
Other providers in McComb, MS
- Vivian Woods
- Jennifer E Wooten
- Courtney Wyant
- Clarence Yeager
- Daniel Araya Yergaw
- Gabriel Zevallos
- Zwound Care
All providers in McComb, MS · Family Medicine Physician in Mississippi
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 23, 2012. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.