Healthcare Provider Details

I. General information

NPI: 1174697346
Provider Name (Legal Business Name): GLENN MILLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2410 S BROAD ST 3RD FLR
PHILADELPHIA PA
19145-4418
US

IV. Provider business mailing address

3831 RAMAGE RUN
HUNTINGDON VALLEY PA
19006-2453
US

V. Phone/Fax

Practice location:
  • Phone: 215-462-6600
  • Fax: 215-462-2650
Mailing address:
  • Phone: 215-938-0254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberMD033553E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: