Healthcare Provider Details

I. General information

NPI: 1184662231
Provider Name (Legal Business Name): GLENN G. HAMM, MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 12/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3512 STATE ROUTE 257
SENECA PA
16346-2946
US

IV. Provider business mailing address

3512 STATE ROUTE 257
SENECA PA
16346-2946
US

V. Phone/Fax

Practice location:
  • Phone: 814-677-3717
  • Fax: 814-677-8914
Mailing address:
  • Phone: 814-677-3717
  • Fax: 814-677-8914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier094770
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerBLUE SHIELD

VIII. Authorized Official

Name: DR. GLENN GORDON HAMM
Title or Position: OWNER
Credential: MD
Phone: 814-677-3717