Healthcare Provider Details

I. General information

NPI: 1700887932
Provider Name (Legal Business Name): GLENN JOHN TRIPPE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 03/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

282 BENEDICT AVE SUITE B
NORWALK OH
44857-2712
US

IV. Provider business mailing address

282 BENEDICT AVE SUITE B
NORWALK OH
44857-2712
US

V. Phone/Fax

Practice location:
  • Phone: 419-668-9409
  • Fax: 419-668-7099
Mailing address:
  • Phone: 419-668-9409
  • Fax: 419-668-7099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35043009T
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: