Healthcare Provider Details

I. General information

NPI: 1487742458
Provider Name (Legal Business Name): GLENN CARL RICHMOND PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 05/19/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 FRANCIS ST DIVISION OF CARDIAC SURGERY
BOSTON MA
02115-6110
US

IV. Provider business mailing address

41 MALL RD
BURLINGTON MA
01805-0001
US

V. Phone/Fax

Practice location:
  • Phone: 617-732-7678
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number804
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA804
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: