Provider Demographics
NPI:1821232281
Name:GLENN WOOD MD PA
Entity Type:Organization
Organization Name:GLENN WOOD MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BEA
Authorized Official - Middle Name:
Authorized Official - Last Name:ESQUIVEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-552-4124
Mailing Address - Street 1:6705 W HWY 290
Mailing Address - Street 2:C1
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78735-8400
Mailing Address - Country:US
Mailing Address - Phone:512-892-7200
Mailing Address - Fax:512-892-7205
Practice Address - Street 1:730 W STASSNEY LN
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-2982
Practice Address - Country:US
Practice Address - Phone:512-892-7200
Practice Address - Fax:512-892-7205
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GLENN WOOD MD PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-28
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF4706208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty