Provider Demographics
NPI:1114980877
Name:BROWN, GLENN (PT)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:BROWN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 MCBRY DR
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901-4407
Mailing Address - Country:US
Mailing Address - Phone:302-423-0236
Mailing Address - Fax:
Practice Address - Street 1:1255 S STATE ST
Practice Address - Street 2:SUITE 7
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-6932
Practice Address - Country:US
Practice Address - Phone:302-423-0236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ100004292251G0304X, 2251S0007X, 2251X0800X, 225100000X
DEJ3-00000412255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
0525769000OtherIBC AMERIHEALTH
88760519OtherBC MD
DECE9861OtherRAILROAD MEDICARE
5070-0076OtherGHMSI
1114980877OtherTRICARE
DE521729459OtherBLUE CROSS BLUE SHIELD
DE0525769000OtherAMERIHEALTH
DE1114980877Medicaid
DE146729900OtherDEPART OF LABOR
DE690991S93Medicare ID - Type Unspecified
DE0525769000OtherAMERIHEALTH
0525769000OtherIBC AMERIHEALTH