Provider Demographics
NPI:1982694378
Name:SUMMERS, GLENN EDSEL JR (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:EDSEL
Last Name:SUMMERS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2699
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32513-2699
Mailing Address - Country:US
Mailing Address - Phone:850-416-6159
Mailing Address - Fax:850-416-7198
Practice Address - Street 1:5153 N 9TH AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8785
Practice Address - Country:US
Practice Address - Phone:850-416-6159
Practice Address - Fax:850-416-7198
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME60639208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL25117AMedicare ID - Type UnspecifiedINDIV PROVIDER NUMBER
FLF78118Medicare UPIN
FLK8128Medicare ID - Type UnspecifiedGROUP PROV NUMBER