Provider Demographics
NPI:1649248659
Name:HA, GLEN J (MD)
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:J
Last Name:HA
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 1:200 LOTHROP STREET
Mailing Address - Street 2:ROOM 3950 CHP CMT
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15213
Mailing Address - Country:US
Mailing Address - Phone:412-647-3553
Mailing Address - Fax:
Practice Address - Street 1:200 LOTHROP ST
Practice Address - Street 2:ROOM 3950 CHP CMT
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15213-2546
Practice Address - Country:US
Practice Address - Phone:412-647-3553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD421754174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101173171Medicaid
PA101173171Medicaid
PA074409G89Medicare ID - Type Unspecified