Provider Demographics
NPI:1821089582
Name:GLENN, MEL B (MD)
Entity Type:Individual
Prefix:DR
First Name:MEL
Middle Name:B
Last Name:GLENN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9142
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-573-2625
Mailing Address - Fax:617-573-2769
Practice Address - Street 1:125 NASHUA ST
Practice Address - Street 2:SRH
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-1198
Practice Address - Country:US
Practice Address - Phone:617-573-2625
Practice Address - Fax:617-573-2769
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA49226208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0181749Medicaid
MA049226OtherTUFTS HEALTH PLAN
MAE05923OtherBCBS MA
B73876Medicare UPIN
MA0181749Medicaid