Provider Demographics
NPI:1700835311
Name:GLENN E. GRAYBEAL, MD, PA
Entity Type:Organization
Organization Name:GLENN E. GRAYBEAL, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:E
Authorized Official - Last Name:GRAYBEAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:302-422-3377
Mailing Address - Street 1:1 SUSSEX AVE
Mailing Address - Street 2:PO BOX 929
Mailing Address - City:MILFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19963-1853
Mailing Address - Country:US
Mailing Address - Phone:302-422-3377
Mailing Address - Fax:302-422-9580
Practice Address - Street 1:1 SUSSEX AVE
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:DE
Practice Address - Zip Code:19963-1853
Practice Address - Country:US
Practice Address - Phone:302-422-3377
Practice Address - Fax:302-422-9580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000073902Medicaid
066383Medicare ID - Type UnspecifiedGROUP PROVIDER ID