Provider Demographics
NPI:1790845949
Name:GLENN, MARY A (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:GLENN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ANGELA
Other - Last Name:GLENN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:495 GOLD STAR HWY
Mailing Address - Street 2:SUITE 120
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-6228
Mailing Address - Country:US
Mailing Address - Phone:860-449-8882
Mailing Address - Fax:860-449-9195
Practice Address - Street 1:495 GOLD STAR HWY
Practice Address - Street 2:SUITE 120
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-6228
Practice Address - Country:US
Practice Address - Phone:860-449-8882
Practice Address - Fax:860-449-9195
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT032910208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001329102Medicaid
010032910CT-04OtherBLUE CROSS BLUE SHIELD
08211695-009OtherCIGNA
329100OtherCONNECTICARE
4351240OtherAETNA
2V6459OtherHEALTH NET
P766722OtherOXFORD
F72417Medicare UPIN