Provider Demographics
NPI:1780866053
Name:GLENN P HOOT MD PHD PS INC
Entity Type:Organization
Organization Name:GLENN P HOOT MD PHD PS INC
Other - Org Name:DBA BROADWAY OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:P
Authorized Official - Last Name:HOOT
Authorized Official - Suffix:
Authorized Official - Credentials:MD PHD
Authorized Official - Phone:360-533-5800
Mailing Address - Street 1:118 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-6215
Mailing Address - Country:US
Mailing Address - Phone:360-532-3773
Mailing Address - Fax:360-533-6545
Practice Address - Street 1:118 W 1ST ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-6215
Practice Address - Country:US
Practice Address - Phone:360-532-3773
Practice Address - Fax:360-533-6545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD32157332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0905420001Medicare NSC