Healthcare Provider Details

I. General information

NPI: 1962484592
Provider Name (Legal Business Name): GLEN R PATRIZIO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 10/09/2023
Certification Date: 10/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 WOODS CT STE 102
HOOD RIVER OR
97031-2919
US

IV. Provider business mailing address

4355 W RIDGE DR
HOOD RIVER OR
97031-7734
US

V. Phone/Fax

Practice location:
  • Phone: 541-436-2960
  • Fax: 541-436-2961
Mailing address:
  • Phone: 541-705-7505
  • Fax: 971-244-9050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License NumberMD24391
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD24391
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License NumberMD60191672
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: