Provider Demographics
NPI:1922010776
Name:GLENN, EDWARD H (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:H
Last Name:GLENN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 MAPLE AVENUE
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787
Mailing Address - Country:US
Mailing Address - Phone:631-265-5777
Mailing Address - Fax:631-265-5797
Practice Address - Street 1:80 MAPLE AVENUE
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787
Practice Address - Country:US
Practice Address - Phone:631-265-5777
Practice Address - Fax:631-265-5797
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2009-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0946002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00657167Medicaid
NY908161Medicare ID - Type Unspecified
B79818Medicare UPIN