Provider Demographics
NPI:1205155199
Name:GLENN J. NOVAK D O INC
Entity type:Organization
Organization Name:GLENN J. NOVAK D O INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:NOVAK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:330-799-1718
Mailing Address - Street 1:51 WESTCHESTER DR
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44515-3902
Mailing Address - Country:US
Mailing Address - Phone:330-799-1718
Mailing Address - Fax:330-799-8328
Practice Address - Street 1:51 WESTCHESTER DR
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44515-3902
Practice Address - Country:US
Practice Address - Phone:330-799-1718
Practice Address - Fax:330-799-8328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-18
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03058207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0766434Medicaid
OH0530663Medicare PIN
OHA80619Medicare UPIN