Healthcare Provider Details

I. General information

NPI: 1750606778
Provider Name (Legal Business Name): ALAN GLENN WOODRUFF M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2010
Last Update Date: 07/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE BADER 6, CRITICAL CARE MEDICINE
BOSTON MA
02115-5724
US

IV. Provider business mailing address

MEDICAL CENTER BLVD
WINSTON SALEM NC
27157-0001
US

V. Phone/Fax

Practice location:
  • Phone: 708-207-7371
  • Fax:
Mailing address:
  • Phone: 336-716-2255
  • Fax: 336-716-3202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberDR.0052733
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number258953
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number2017-00953
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: