Provider Demographics
NPI:1447242342
Name:GLOVER, BRIAN KEITH (PT)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:KEITH
Last Name:GLOVER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3620 HARLEM RD STE 2
Mailing Address - Street 2:
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14215-2042
Mailing Address - Country:US
Mailing Address - Phone:716-446-9500
Mailing Address - Fax:716-446-9501
Practice Address - Street 1:3620 HARLEM RD STE 2
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14215-2042
Practice Address - Country:US
Practice Address - Phone:716-446-9500
Practice Address - Fax:716-446-9501
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-17
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022612174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000626742002OtherBC/BS
NY02167366Medicaid
P00173532OtherRR MEDICARE/PALMETTO GBA
P00173532OtherRR MEDICARE/PALMETTO GBA
NY000626742002OtherBC/BS