Provider Demographics
NPI:1649218835
Name:KANE, GLENN I (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:I
Last Name:KANE
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:PO BOX 4419
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91365-4419
Mailing Address - Country:US
Mailing Address - Phone:800-358-9787
Mailing Address - Fax:818-587-2493
Practice Address - Street 1:1350 W COVINA BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3245
Practice Address - Country:US
Practice Address - Phone:909-599-6811
Practice Address - Fax:818-587-2493
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG33423207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA930045580OtherRAILROAD MEDICARE
CA00G334230OtherBLUE SHIELD
CA00G334230Medicaid
CAWG33423EMedicare ID - Type Unspecified
CA00G334230OtherBLUE SHIELD