Provider Demographics
NPI:1821056433
Name:GLENN, JOHN L (MD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:L
Last Name:GLENN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:427 GUY PARK AVE - PRIMARY & SPECIALTY CARE DEPT.
Mailing Address - Street 2:ST. MARY'S HOSPITAL AT AMSTERDAM
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010
Mailing Address - Country:US
Mailing Address - Phone:518-841-7430
Mailing Address - Fax:518-841-7121
Practice Address - Street 1:84 E. STATE ST
Practice Address - Street 2:ST. MARY'S HOSPITAL, GLOVERSVILLE FAM HLTH CNTR
Practice Address - City:GLOVERSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12078
Practice Address - Country:US
Practice Address - Phone:518-773-8894
Practice Address - Fax:518-773-8125
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2010-09-02
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Provider Licenses
StateLicense IDTaxonomies
NY1575271208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00890859Medicaid
C59167Medicare UPIN
NY00890859Medicaid