Provider Demographics
NPI:1013988740
Name:GLENN FREED DO PC
Entity Type:Organization
Organization Name:GLENN FREED DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:FREED
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:570-622-3366
Mailing Address - Street 1:100 SCHUYLKILL MEDICAL PLZ
Mailing Address - Street 2:SUITE 101
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-3663
Mailing Address - Country:US
Mailing Address - Phone:570-622-3366
Mailing Address - Fax:570-622-6638
Practice Address - Street 1:100 SCHUYLKILL MEDICAL PLZ
Practice Address - Street 2:SUITE 101
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-3663
Practice Address - Country:US
Practice Address - Phone:570-622-3366
Practice Address - Fax:570-622-6638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-31
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA02700200OtherCAPITAL BLUE CROSS
1677099OtherHIGHMARK BS
PAP00178931OtherTRAVELERS MEDICARE
PA087774Medicare PIN