Provider Demographics
NPI:1093793598
Name:IRWIN, GLENN EDGAR JR (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:EDGAR
Last Name:IRWIN
Suffix:JR
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 1:900 CHESTNUT STREET EXT STE A
Mailing Address - Street 2:
Mailing Address - City:BRADFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16701-2298
Mailing Address - Country:US
Mailing Address - Phone:814-817-2870
Mailing Address - Fax:814-368-8041
Practice Address - Street 1:900 CHESTNUT STREET EXT STE A
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:PA
Practice Address - Zip Code:16701
Practice Address - Country:US
Practice Address - Phone:814-817-2870
Practice Address - Fax:814-368-8041
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD028763E207P00000X, 208D00000X, 207QA0505X
NV15754207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV15754OtherSTATE LICENSE
NV1093793598Medicaid