1790845949 NPI number — MARY A GLENN M.D.

Table of content: MARY A GLENN M.D. (NPI 1790845949)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790845949 NPI number — MARY A GLENN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLENN
Provider First Name:
MARY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GLENN
Provider Other First Name:
MARY
Provider Other Middle Name:
ANGELA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1790845949
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:
495 GOLD STAR HWY
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
GROTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06340-6228
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-449-8882
Provider Business Mailing Address Fax Number:
860-449-9195

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
495 GOLD STAR HWY
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
GROTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06340-6228
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-449-8882
Provider Business Practice Location Address Fax Number:
860-449-9195
Provider Enumeration Date:
12/11/2006

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: 208000000X , with the licence number:  032910 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 001329102 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010032910CT-04 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 08211695-009 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 329100 . This is a "CONNECTICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4351240 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2V6459 . This is a "HEALTH NET" identifier . This identifiers is of the category "OTHER".
  • Identifier: P766722 . This is a "OXFORD" identifier . This identifiers is of the category "OTHER".




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