Provider Demographics
NPI:1619026598
Name:GLASS, RICHARD EDWIN (DC)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:EDWIN
Last Name:GLASS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 E WESTFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:ROSELLE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07204-2084
Mailing Address - Country:US
Mailing Address - Phone:908-245-8844
Mailing Address - Fax:908-245-6230
Practice Address - Street 1:236 E WESTFIELD AVE
Practice Address - Street 2:
Practice Address - City:ROSELLE PARK
Practice Address - State:NJ
Practice Address - Zip Code:07204-2084
Practice Address - Country:US
Practice Address - Phone:908-245-8844
Practice Address - Fax:908-245-6230
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMCO2870111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1096001Medicaid
NJGL450028Medicare ID - Type Unspecified