Healthcare Provider Details

I. General information

NPI: 1518234145
Provider Name (Legal Business Name): GLENWOOD MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2011
Last Update Date: 11/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11572 FRANCIS LEWIS BLVD
CAMBRIA HEIGHTS NY
11411-1028
US

IV. Provider business mailing address

11572 FRANCIS LEWIS BLVD
CAMBRIA HEIGHTS NY
11411-1028
US

V. Phone/Fax

Practice location:
  • Phone: 718-276-8666
  • Fax: 718-276-4158
Mailing address:
  • Phone: 718-276-8666
  • Fax: 718-276-4158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License Number192310
License Number StateNY

VIII. Authorized Official

Name: OSAFRADU OPAM
Title or Position: MD
Credential:
Phone: 718-276-8666