Provider Demographics
NPI:1114985348
Name:ROSS, GLEN (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:ROSS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:20 GUEST ST
Mailing Address - Street 2:STE 225
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-2065
Mailing Address - Country:US
Mailing Address - Phone:617-738-8642
Mailing Address - Fax:617-202-4172
Practice Address - Street 1:20 GUEST ST
Practice Address - Street 2:STE 225
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-2065
Practice Address - Country:US
Practice Address - Phone:617-738-8642
Practice Address - Fax:617-202-4172
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2019-12-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA80933207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1114985348Medicare NSC