Provider Demographics
NPI:1164485199
Name:EDGECOMBE, GLENN ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:ROBERT
Last Name:EDGECOMBE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:7700 OLD BRANCH AVE
Mailing Address - Street 2:STE B201
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735
Mailing Address - Country:US
Mailing Address - Phone:301-868-0150
Mailing Address - Fax:301-868-0243
Practice Address - Street 1:7700 OLD BRANCH AVE
Practice Address - Street 2:STE B201
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735
Practice Address - Country:US
Practice Address - Phone:301-868-0150
Practice Address - Fax:301-868-0243
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0023826207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC73810001OtherCAREFIRST BCBS
MD855349OtherMAMSI
MD494356OtherNCPPO
MD41308904OtherCAREFIRST BCBS
MD41308904OtherCAREFIRST BCBS
DC189208Medicare ID - Type Unspecified