Healthcare Provider Details

I. General information

NPI: 1174502140
Provider Name (Legal Business Name): GLENNON JOHN OGRADY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 03/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 DORCHESTER AVENUE FAMILY MEDICINE
DORCHESTER MA
02124
US

IV. Provider business mailing address

2100 DORCHESTER AVENUE FAMILY MEDICINE
DORCHESTER MA
02124
US

V. Phone/Fax

Practice location:
  • Phone: 617-506-4970
  • Fax: 978-686-4137
Mailing address:
  • Phone: 617-506-4970
  • Fax: 978-686-4137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number59292
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: