Provider Demographics
NPI:1073740130
Name:GLENN WOOD MD PA
Entity Type:Organization
Organization Name:GLENN WOOD MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALER
Authorized Official - Prefix:MS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:RENE
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-788-4801
Mailing Address - Street 1:6705 W HWY 290
Mailing Address - Street 2:C1
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78735-8400
Mailing Address - Country:US
Mailing Address - Phone:512-788-4801
Mailing Address - Fax:
Practice Address - Street 1:7112 ED BLUESTEIN BLVD
Practice Address - Street 2:100
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-2900
Practice Address - Country:US
Practice Address - Phone:512-892-7200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-16
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX153715108Medicaid