Provider Demographics
NPI:1326102252
Name:GLEN E SUTHERLAND MD PA
Entity Type:Organization
Organization Name:GLEN E SUTHERLAND MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:SUTHERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-772-6781
Mailing Address - Street 1:1930 NE 47TH ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-7718
Mailing Address - Country:US
Mailing Address - Phone:954-772-6781
Mailing Address - Fax:954-772-6793
Practice Address - Street 1:1930 NE 47TH ST
Practice Address - Street 2:SUITE 301
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-7718
Practice Address - Country:US
Practice Address - Phone:954-772-6781
Practice Address - Fax:954-772-6793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL30881207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL037094100Medicaid
FL68150XMedicare ID - Type Unspecified
FLD57801Medicare UPIN