Provider Demographics
NPI:1750640546
Name:GLEN P WAINEN, MD, LLC
Entity type:Organization
Organization Name:GLEN P WAINEN, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:P
Authorized Official - Last Name:WAINEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:908-813-9700
Mailing Address - Street 1:57 US HIGHWAY 46
Mailing Address - Street 2:STE 107
Mailing Address - City:HACKETTSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07840-2695
Mailing Address - Country:US
Mailing Address - Phone:908-813-9700
Mailing Address - Fax:908-813-0033
Practice Address - Street 1:57 US HIGHWAY 46
Practice Address - Street 2:STE 107
Practice Address - City:HACKETTSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07840-2695
Practice Address - Country:US
Practice Address - Phone:908-813-9700
Practice Address - Fax:908-813-0033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-14
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA60125207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6718890001Medicare NSC