Provider Demographics
NPI:1154315711
Name:GLAVIN, EUGENE M (MD)
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:M
Last Name:GLAVIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 ROYAL RD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-8929
Mailing Address - Country:US
Mailing Address - Phone:302-547-3399
Mailing Address - Fax:302-358-2066
Practice Address - Street 1:252 S. 4TH STREET
Practice Address - Street 2:GOOD SAMARITAN HOSPITAL
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042
Practice Address - Country:US
Practice Address - Phone:717-270-7644
Practice Address - Fax:302-358-2066
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10005739207R00000X, 208000000X
PAMD072803L2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000024323Medicaid
DEH67692Medicare UPIN