Provider Demographics
NPI:1073590121
Name:MCLINTOCK, GLENN R (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:R
Last Name:MCLINTOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:301 LIPPINCOTT DR STE 410
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4197
Mailing Address - Country:US
Mailing Address - Phone:856-355-0340
Mailing Address - Fax:856-355-0330
Practice Address - Street 1:216 HADDON AVE
Practice Address - Street 2:
Practice Address - City:HADDON TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08108-2809
Practice Address - Country:US
Practice Address - Phone:856-854-6600
Practice Address - Fax:856-854-6700
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2020-10-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA06771400207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7680309Medicaid
G79634Medicare UPIN
NJ7680309Medicaid