Healthcare Provider Details

I. General information

NPI: 1538377213
Provider Name (Legal Business Name): GREGORY MARK GLENN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 09/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14525 MONTEVIDEO RD
POOLESVILLE MD
20837-8858
US

IV. Provider business mailing address

14525 MONTEVIDEO RD
POOLESVILLE MD
20837-8858
US

V. Phone/Fax

Practice location:
  • Phone: 240-899-5566
  • Fax:
Mailing address:
  • Phone: 301-216-0742
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080H0002X
TaxonomyPediatric Hospice and Palliative Medicine Physician
License NumberM36700
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: