Provider Demographics
NPI:1407841067
Name:FREED, GLENN S (DO)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:S
Last Name:FREED
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:GLENN
Other - Middle Name:S
Other - Last Name:FREED
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:128 W 14TH ST
Mailing Address - Street 2:
Mailing Address - City:HAZLETON
Mailing Address - State:PA
Mailing Address - Zip Code:18201-3266
Mailing Address - Country:US
Mailing Address - Phone:570-366-4606
Mailing Address - Fax:866-735-4585
Practice Address - Street 1:100 SCHUYLKILL MEDICAL PLZ
Practice Address - Street 2:STE 101
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-3663
Practice Address - Country:US
Practice Address - Phone:570-366-4606
Practice Address - Fax:866-735-4585
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS004145L207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D73246Medicare UPIN
PA415719Medicare PIN