Healthcare Provider Details

I. General information

NPI: 1912975517
Provider Name (Legal Business Name): GLENN S. GERHARD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 03/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 N. BROAD STREET
PHILADELPHIA PA
19140
US

IV. Provider business mailing address

2450 W. HUNTING PARK AVENUE
PHILADELPHIA PA
19129
US

V. Phone/Fax

Practice location:
  • Phone: 215-707-4353
  • Fax: 215-707-2781
Mailing address:
  • Phone: 215-707-8561
  • Fax: 215-707-3677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License NumberMD044882E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: