Provider Demographics
NPI:1437121167
Name:KORENKO, GLENN M (PT)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:M
Last Name:KORENKO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11550 OLDE STONE CT
Mailing Address - Street 2:
Mailing Address - City:CONCORD TWP
Mailing Address - State:OH
Mailing Address - Zip Code:44077-8933
Mailing Address - Country:US
Mailing Address - Phone:440-639-1123
Mailing Address - Fax:440-639-1708
Practice Address - Street 1:11550 OLDE STONE CT
Practice Address - Street 2:
Practice Address - City:CONCORD TWP
Practice Address - State:OH
Practice Address - Zip Code:44077-8933
Practice Address - Country:US
Practice Address - Phone:440-639-1123
Practice Address - Fax:440-639-1708
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2012225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2534234Medicaid
OHKO4149561Medicare ID - Type UnspecifiedPHYSICAL THERAPY