Provider Demographics
NPI:1659323426
Name:MCGLYNN, FRED J (MD)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:J
Last Name:MCGLYNN
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 71690
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23255-1690
Mailing Address - Country:US
Mailing Address - Phone:804-285-2300
Mailing Address - Fax:804-285-8420
Practice Address - Street 1:1501 MAPLE AVE
Practice Address - Street 2:NW MOB SUITE 200
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-2553
Practice Address - Country:US
Practice Address - Phone:804-285-2300
Practice Address - Fax:804-285-8420
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101032933174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA227696OtherANTHEM
VA006494404Medicaid
200007793OtherGEORGIA RR MEDICARE
201953777Medicare ID - Type Unspecified
VA006494404Medicaid