Provider Demographics
NPI:1598780165
Name:CRAWFORD, GLEN H (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:H
Last Name:CRAWFORD
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 1:822 PINE ST
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-6187
Mailing Address - Country:US
Mailing Address - Phone:267-519-0154
Mailing Address - Fax:267-519-0597
Practice Address - Street 1:822 PINE ST
Practice Address - Street 2:SUITE 2A
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-6187
Practice Address - Country:US
Practice Address - Phone:267-519-0154
Practice Address - Fax:267-519-0597
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD421221207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1008871430001Medicaid
H79846Medicare UPIN
PA067967Medicare PIN