Provider Demographics
NPI:1114971066
Name:PISK, GLENN HOWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:HOWARD
Last Name:PISK
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2129 W OREGON AVE
Mailing Address - Street 2:FIRST FLOOR REAR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-4131
Mailing Address - Country:US
Mailing Address - Phone:215-462-6106
Mailing Address - Fax:215-462-5922
Practice Address - Street 1:2129 W OREGON AVE
Practice Address - Street 2:FIRST FLOOR REAR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-4131
Practice Address - Country:US
Practice Address - Phone:215-462-6106
Practice Address - Fax:215-462-5922
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD0411084L2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016075460001Medicaid
PAE93071Medicare UPIN