Provider Demographics
NPI:1053364828
Name:IMLAY, GLEN P (MD)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:P
Last Name:IMLAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-886-9403
Mailing Address - Fax:740-446-5153
Practice Address - Street 1:98 STATE ST
Practice Address - Street 2:
Practice Address - City:PROCTORVILLE
Practice Address - State:OH
Practice Address - Zip Code:45669-8163
Practice Address - Country:US
Practice Address - Phone:740-886-9403
Practice Address - Fax:740-446-5153
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20826208100000X
OH35-08-0873208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2333906OtherMOLINA MEDICAID
OH000000185246OtherUNISON MEDICAID
000000227912OtherANTHEM BCBS
WV2003261000Medicaid
OH310917085124OtherCARESOURCE MEDICAID
OH2333906Medicaid
001714143OtherMOUNTAIN STATE BCBS
250013535OtherRR MEDICARE
OH2333906OtherMOLINA MEDICAID
H62526Medicare UPIN
250013535OtherRR MEDICARE
WV4084324Medicare PIN