Provider Demographics
NPI:1083966055
Name:GLENN R. EDGECOMBE, MD,PC
Entity Type:Organization
Organization Name:GLENN R. EDGECOMBE, MD,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:EDGECOMBE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-868-0150
Mailing Address - Street 1:7700 OLD BRANCH AVE
Mailing Address - Street 2:B201
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-1628
Mailing Address - Country:US
Mailing Address - Phone:301-868-0150
Mailing Address - Fax:301-868-0243
Practice Address - Street 1:7700 OLD BRANCH AVE
Practice Address - Street 2:B201
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-1628
Practice Address - Country:US
Practice Address - Phone:301-868-0150
Practice Address - Fax:301-868-0243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0023826207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD020751900Medicaid