Provider Demographics
NPI:1144201971
Name:PGP FAMILY PHYSICIANS, LLC
Entity Type:Organization
Organization Name:PGP FAMILY PHYSICIANS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:GLOGAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:206-478-9220
Mailing Address - Street 1:8607 TEMPLE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46809-3048
Mailing Address - Country:US
Mailing Address - Phone:260-478-9220
Mailing Address - Fax:260-478-9172
Practice Address - Street 1:8607 TEMPLE DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46809-3048
Practice Address - Country:US
Practice Address - Phone:260-478-9220
Practice Address - Fax:260-478-9172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN224620Medicare ID - Type Unspecified