Provider Demographics
NPI:1750345229
Name:GLENN, JERRY (MD, PHD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:GLENN
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 S ATHERTON ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-8324
Mailing Address - Country:US
Mailing Address - Phone:814-466-2300
Mailing Address - Fax:814-466-2822
Practice Address - Street 1:3901 S ATHERTON ST
Practice Address - Street 2:SUITE 2
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-8324
Practice Address - Country:US
Practice Address - Phone:814-466-2300
Practice Address - Fax:814-466-2822
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD030666E2086X0206X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA30477OtherGEISINGER HEALTH PLAN
PA50047400OtherCAPITAL BLUE CROSS
PA0009667720004Medicaid
PAGL116265OtherHIGHMARK BLUE SHIELD
PA50047400OtherCAPITAL BLUE CROSS
PAGL116265OtherHIGHMARK BLUE SHIELD