Provider Demographics
NPI:1558443465
Name:STROHM, GLEN HENRY (MD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:HENRY
Last Name:STROHM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 W. ST. MARY'S ROAD
Mailing Address - Street 2:108
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745
Mailing Address - Country:US
Mailing Address - Phone:520-884-0921
Mailing Address - Fax:520-884-7670
Practice Address - Street 1:1601 W. ST. MARY'S ROAD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745
Practice Address - Country:US
Practice Address - Phone:520-884-0921
Practice Address - Fax:520-884-7670
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11239207U00000X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Not Answered207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ236100Medicaid
AZ22WCGDG1CMedicare ID - Type Unspecified
AZ236100Medicaid