Provider Demographics
NPI:1609937663
Name:KASHURBA, GLENN JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:JOSEPH
Last Name:KASHURBA
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 1:113 S CENTER AVE
Mailing Address - Street 2:STE 1
Mailing Address - City:SOMERSET
Mailing Address - State:PA
Mailing Address - Zip Code:15501-2063
Mailing Address - Country:US
Mailing Address - Phone:814-445-9695
Mailing Address - Fax:814-444-8812
Practice Address - Street 1:113 S CENTER AVE
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:PA
Practice Address - Zip Code:15501-2057
Practice Address - Country:US
Practice Address - Phone:814-445-9695
Practice Address - Fax:814-444-8812
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD029895E2084P0804X
MDD00354192084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA435297OtherHIGHMARK
1397413OtherUMWA
PA001132194Medicaid
435297RGDMedicare PIN
435297Medicare PIN
PA435297OtherHIGHMARK