Provider Demographics
NPI:1093826752
Name:HERMAN, GLENN STEWART (DC)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:STEWART
Last Name:HERMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:NAUGATUCK
Mailing Address - State:CT
Mailing Address - Zip Code:06770-2806
Mailing Address - Country:US
Mailing Address - Phone:203-729-4047
Mailing Address - Fax:203-723-9103
Practice Address - Street 1:331 CHURCH ST
Practice Address - Street 2:
Practice Address - City:NAUGATUCK
Practice Address - State:CT
Practice Address - Zip Code:06770-2806
Practice Address - Country:US
Practice Address - Phone:203-729-4047
Practice Address - Fax:203-723-9103
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT708111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004092508Medicaid
CT050000708CT01OtherANTHEM BLUE CROSS/BLUE SH
CT050000708CT01OtherANTHEM BLUE CROSS/BLUE SH