Healthcare Provider Details

I. General information

NPI: 1164485199
Provider Name (Legal Business Name): GLENN ROBERT EDGECOMBE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7700 OLD BRANCH AVE STE B201
CLINTON MD
20735
US

IV. Provider business mailing address

7700 OLD BRANCH AVE STE B201
CLINTON MD
20735
US

V. Phone/Fax

Practice location:
  • Phone: 301-868-0150
  • Fax: 301-868-0243
Mailing address:
  • Phone: 301-868-0150
  • Fax: 301-868-0243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0023826
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: