Provider Demographics
NPI:1730394545
Name:GLEN G.GUILLET M.D.,P.A.
Entity type:Organization
Organization Name:GLEN G.GUILLET M.D.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:G
Authorized Official - Last Name:GUILLET
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:409-896-5901
Mailing Address - Street 1:5875 N MAJOR DR
Mailing Address - Street 2:SUITE 214
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77713-9013
Mailing Address - Country:US
Mailing Address - Phone:409-896-5901
Mailing Address - Fax:409-896-5910
Practice Address - Street 1:5875 N MAJOR DR
Practice Address - Street 2:SUITE 214
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77713-9013
Practice Address - Country:US
Practice Address - Phone:409-896-5901
Practice Address - Fax:409-896-5910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD2455261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0007PMOtherBCBS
TX128065306Medicaid
TX128065306Medicaid
TX00Y199Medicare PIN