Provider Demographics
NPI:1972272268
Name:GLENVILLE MEDICAL PROFESSIONAL CORP
Entity Type:Organization
Organization Name:GLENVILLE MEDICAL PROFESSIONAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:PENN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-551-2750
Mailing Address - Street 1:3599 BOULEVARD STE B
Mailing Address - Street 2:
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-1300
Mailing Address - Country:US
Mailing Address - Phone:310-551-2750
Mailing Address - Fax:888-972-8038
Practice Address - Street 1:3599 BOULEVARD STE B
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-1300
Practice Address - Country:US
Practice Address - Phone:310-551-2750
Practice Address - Fax:888-972-8038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty