1356397574 NPI number — DR. LARRY R GLAZERMAN MD

Table of content: DR. LARRY R GLAZERMAN MD (NPI 1356397574)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356397574 NPI number — DR. LARRY R GLAZERMAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLAZERMAN
Provider First Name:
LARRY
Provider Middle Name:
R
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:
1356397574
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
625 N SHIPLEY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19801-2228
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-655-7296
Provider Business Mailing Address Fax Number:
302-655-1907

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
625 N SHIPLEY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19801-2228
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-655-7296
Provider Business Practice Location Address Fax Number:
302-655-1907
Provider Enumeration Date:
05/26/2006

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: 207V00000X , with the licence number:  MD019651E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: ME102634 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: C1-0011359 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 037452 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0735550 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 160047167 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 64329 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 000326900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 037452 . This is a "KEYSTONE CENTRAL" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 4265977 . This is a "AETNA PPO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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