Provider Demographics
NPI:1972513745
Name:PRENTICE, GLENN D (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:D
Last Name:PRENTICE
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 1:22 BRAMHALL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3134
Mailing Address - Country:US
Mailing Address - Phone:207-662-3183
Mailing Address - Fax:207-662-6783
Practice Address - Street 1:66 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3344
Practice Address - Country:US
Practice Address - Phone:207-662-3183
Practice Address - Fax:207-662-6783
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD141532084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEEX5753Medicare PIN
MEMM6050Medicare PIN
C48918Medicare UPIN