Provider Demographics
NPI:1275503286
Name:COOK, GLENDA J (MD)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:J
Last Name:COOK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 CLOVERLEAF RD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17022-9320
Mailing Address - Country:US
Mailing Address - Phone:717-653-1467
Mailing Address - Fax:717-653-1001
Practice Address - Street 1:418 CLOVERLEAF RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:PA
Practice Address - Zip Code:17022-9320
Practice Address - Country:US
Practice Address - Phone:717-653-1467
Practice Address - Fax:717-653-1001
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD053135L207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA110237772OtherRAILROAD MEDICARE
PA50000533OtherCAPITAL BLUE CROSS
PAF87562OtherHEALTH ASSURANCE
PAP004427OtherGATEWAY HEALTH PLAN
PA0014654500008Medicaid
PA36826 S101OtherGEISINGER HEALTH PLAN
PA4505677OtherAETNA NON-HMO
PA143903OtherHIGHMARK BLUE SHIELD
PA513684OtherAETNA HMIO
PA4505677OtherAETNA NON-HMO
PAF87562OtherHEALTH ASSURANCE