Healthcare Provider Details

I. General information

NPI: 1164486783
Provider Name (Legal Business Name): GLENN R SLOMIN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 09/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 N WICKHAM RD SUITE 300
MELBOURNE FL
32935-8662
US

IV. Provider business mailing address

2222 S HARBOR CITY BLVD
MELBOURNE FL
32901-5594
US

V. Phone/Fax

Practice location:
  • Phone: 321-308-5050
  • Fax: 321-984-9497
Mailing address:
  • Phone: 321-541-1783
  • Fax: 321-504-0118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDS5906
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: