NPIMap

Individual provider Active NPI

Justin A Glass, M.D.

  • Family Medicine Physician
  • Boise, ID
National Provider Identifier
1194820852
Registry record updated Jul 22, 2009
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
M-10405 Issued in ID
Practice address
777 N Raymond St
Boise, ID 83704-9251
Phone
(208) 367-6030
Fax
(208) 322-7018
NPI assigned
Sep 14, 2006
Last updated
Jul 22, 2009By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jul 22, 2009

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

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 56066 GA
Family Medicine Physician 207Q00000X M-10405 ID Primary

Addresses

Primary practice location

777 N Raymond St
Boise, ID 83704-9251

Mailing address

777 N Raymond St
Boise, ID 83704-9251
Phone (208) 367-6030

Other identifiers 8

IdentifierTypeStateIssuer
8HD082OtherTOADALENA MEDICARE PIN
42701279MedicaidCO
565179MedicaidAZ
808154100MedicaidID
1194820852MedicaidNM
807782300MedicaidID
8HD081OtherSANOSTEE MEDICARE PIN
8HZ07COtherNNMC MEDICARE PIN

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ID
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20080929000598 ID Practitioner - Family Practice 1951351071 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
University of New Mexico School of Medicine, 1997
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Full Circle Health IncGroup PAC ID 6709986797, 106 clinicians

Practice addresses (Care Compare)

2275 S Eagle Rd
Meridian, ID 83642-2620
Phone (208) 514-2520

708 E Wythe Creek CT
Kuna, ID 83634-5005
Phone (208) 922-5130

777 N Raymond St
Boise, ID 83704-9251
Phone (208) 514-2500

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
56066GAMDFamily Medicine Physician
M-10405IDMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Full Circle Health, Inc. CurrentSince Oct 1, 2008 Accepting new patients
DHHS, PHS, Naihs, Shiprock Hospital Past Accepting new patients
DHHS, PHS, Naihs, Shiprock Hospital Past Accepting new patients
St Lukes Regional Medical Center Past Accepting new patients

Locations

325 W Idaho St
Boise, ID 83702
Phone (208) 514-2525

6565 W Emerald St
Boise, ID 83704
Phone (208) 377-5055

777 N Raymond St
Boise, ID 83704
Phone (208) 367-6030

215 W 35th St
Garden City, ID 83714
Phone (208) 384-5200

2275 S Eagle Rd
Ste 120
Meridian, ID 83642
Phone (208) 514-2520

Interoperability endpoints

  • Direct secure messaging: jglass295111@direct.ochin.org

Ownership & related parties

All facility ownership & control disclosures 5

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Full Circle HealthBoise, ID, CCN 131835 Federally qualified health center Corporate Director Aug 26, 2013
Full Circle HealthBoise, ID, CCN 131839 Federally qualified health center Corporate Director Aug 26, 2013
Full Circle HealthMeridian, ID, CCN 131844 Federally qualified health center Corporate Director Aug 26, 2013
Full Circle HealthBoise, ID, CCN 131843 Federally qualified health center W-2 Managing Employee Aug 26, 2013
Full Circle HealthKuna, ID, CCN 131857 Federally qualified health center Corporate Director Aug 26, 2013

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Organizations & group practices 4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 7

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

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

{
    "created_epoch": "1158192000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1248220800000",
    "number": "1194820852",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "777 N RAYMOND ST",
            "city": "BOISE",
            "state": "ID",
            "postal_code": "837049251",
            "telephone_number": "208-367-6030",
            "fax_number": "208-322-7018"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "777 N RAYMOND ST",
            "city": "BOISE",
            "state": "ID",
            "postal_code": "837049251",
            "telephone_number": "208-367-6030",
            "fax_number": "208-322-7018"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "GLASS",
        "first_name": "JUSTIN",
        "middle_name": "A",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-09-14",
        "last_updated": "2009-07-22",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "GA",
            "license": "56066",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "ID",
            "license": "M-10405",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "TOADALENA MEDICARE PIN",
            "identifier": "8HD082",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "42701279",
            "state": "CO"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "565179",
            "state": "AZ"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "808154100",
            "state": "ID"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1194820852",
            "state": "NM"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "807782300",
            "state": "ID"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "SANOSTEE MEDICARE PIN",
            "identifier": "8HD081",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NNMC MEDICARE PIN",
            "identifier": "8HZ07C",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Boise, ID

Sources for this page

Verify at the official NPI Registry.