Provider Demographics
NPI:1770712804
Name:GLENN WOOD MD PA
Entity type:Organization
Organization Name:GLENN WOOD MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALER
Authorized Official - Prefix:MS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:R
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-788-4801
Mailing Address - Street 1:6705 W HIGHWAY 290
Mailing Address - Street 2:C1
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78735-8400
Mailing Address - Country:US
Mailing Address - Phone:512-788-4801
Mailing Address - Fax:
Practice Address - Street 1:6425 S IH 35
Practice Address - Street 2:100
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78744-4271
Practice Address - Country:US
Practice Address - Phone:512-788-4801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-10
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty