Healthcare Provider Details

I. General information

NPI: 1447208459
Provider Name (Legal Business Name): GLENN A. STAYER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 08/12/2020
Certification Date: 08/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N ACADEMY AVE
DANVILLE PA
17822-1405
US

IV. Provider business mailing address

100 N ACADEMY AVE CREDENTIALS DEPT
DANVILLE PA
17822-4903
US

V. Phone/Fax

Practice location:
  • Phone: 570-271-6012
  • Fax: 570-271-9723
Mailing address:
  • Phone: 570-271-6144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD038769E
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License NumberMD038769E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: