Healthcare Provider Details

I. General information

NPI: 1467574640
Provider Name (Legal Business Name): CHARLES T MCGLYNN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 MONUMENT RD
PHILADELPHIA PA
19131-1625
US

IV. Provider business mailing address

101 E OLNEY AVE SUITE 505
PHILADELPHIA PA
19120-2421
US

V. Phone/Fax

Practice location:
  • Phone: 215-877-2000
  • Fax:
Mailing address:
  • Phone: 215-254-2630
  • Fax: 215-254-2599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD040175L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: