Provider Demographics
NPI:1295895894
Name:ATLAS, GLEN MARK (MD)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:MARK
Last Name:ATLAS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:30 BERGEN ST
Mailing Address - Street 2:ADMC 12 1205
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07107-3000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 BERGEN ST
Practice Address - Street 2:LEVEL E
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-2496
Practice Address - Country:US
Practice Address - Phone:973-972-5787
Practice Address - Fax:973-972-4172
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA07119100207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8377201Medicaid
NJF71368Medicare UPIN
NJ8377201Medicaid