1164485199 NPI number — DR. GLENN ROBERT EDGECOMBE MD

Table of content: DR. GLENN ROBERT EDGECOMBE MD (NPI 1164485199)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164485199 NPI number — DR. GLENN ROBERT EDGECOMBE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDGECOMBE
Provider First Name:
GLENN
Provider Middle Name:
ROBERT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164485199
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7700 OLD BRANCH AVE
Provider Second Line Business Mailing Address:
STE B201
Provider Business Mailing Address City Name:
CLINTON
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20735
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-868-0150
Provider Business Mailing Address Fax Number:
301-868-0243

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7700 OLD BRANCH AVE
Provider Second Line Business Practice Location Address:
STE B201
Provider Business Practice Location Address City Name:
CLINTON
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20735
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-868-0150
Provider Business Practice Location Address Fax Number:
301-868-0243
Provider Enumeration Date:
04/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  D0023826 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 73810001 . This is a "CAREFIRST BCBS" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 855349 . This is a "MAMSI" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 494356 . This is a "NCPPO" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 41308904 . This is a "CAREFIRST BCBS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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