Provider Demographics
NPI:1114271053
Name:GLENN S. PRESCOD, M.D., M.P.H., INC.
Entity Type:Organization
Organization Name:GLENN S. PRESCOD, M.D., M.P.H., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:S
Authorized Official - Last Name:PRESCOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-725-3600
Mailing Address - Street 1:333 SCHOOL ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-5334
Mailing Address - Country:US
Mailing Address - Phone:401-725-3600
Mailing Address - Fax:401-728-8760
Practice Address - Street 1:333 SCHOOL ST
Practice Address - Street 2:SUITE 301
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-5334
Practice Address - Country:US
Practice Address - Phone:401-725-3600
Practice Address - Fax:401-728-8760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-30
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X
RI08767207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9020656Medicaid
RIF94922Medicare UPIN