Provider Demographics
NPI:1871681239
Name:FOSS, GLENN JEFFREY (DC)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:JEFFREY
Last Name:FOSS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 NEWARK POMTON TPKE
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07457
Mailing Address - Country:US
Mailing Address - Phone:973-616-4555
Mailing Address - Fax:973-616-3430
Practice Address - Street 1:18 NEWARK POMTON TPKE
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:NJ
Practice Address - Zip Code:07457
Practice Address - Country:US
Practice Address - Phone:973-616-4555
Practice Address - Fax:973-616-3430
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00465700111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
612488PHLMedicare ID - Type Unspecified