Provider Demographics
NPI:1588637847
Name:BROOKS, GLEN S (MD)
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:S
Last Name:BROOKS
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 1:776 LONGMEADOW ST
Mailing Address - Street 2:
Mailing Address - City:LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01106-2219
Mailing Address - Country:US
Mailing Address - Phone:413-565-4400
Mailing Address - Fax:413-565-4411
Practice Address - Street 1:776 LONGMEADOW ST
Practice Address - Street 2:
Practice Address - City:LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01106-2219
Practice Address - Country:US
Practice Address - Phone:413-565-4400
Practice Address - Fax:413-565-4411
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAD87121Medicare UPIN
MAJ09934Medicare ID - Type Unspecified