Provider Demographics
NPI:1083669964
Name:VANDERVER, GLENN BRUCE GRIMES (MD)
Entity Type:Individual
Prefix:
First Name:GLENN BRUCE
Middle Name:GRIMES
Last Name:VANDERVER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:785 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-4232
Mailing Address - Country:US
Mailing Address - Phone:717-263-9555
Mailing Address - Fax:717-217-4218
Practice Address - Street 1:112 N 7TH ST
Practice Address - Street 2:
Practice Address - City:CHAMBERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17201-1720
Practice Address - Country:US
Practice Address - Phone:717-217-4300
Practice Address - Fax:717-217-4217
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD447885207R00000X, 2083P0901X, 208M00000X
MDD0063178207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD647682 01OtherCAREFIRST BC BS
PA102820537Medicaid
WV3810005850Medicaid
DCJ697 0007OtherBLUE CHOICE
MDKS04OtherMEDICARE
MDP00337741OtherTRAVELERS MEDICARE
MD415402900Medicaid
WV3810005850Medicaid
MD137266ZA4GMedicare PIN