Healthcare Provider Details

I. General information

NPI: 1750345229
Provider Name (Legal Business Name): JERRY GLENN M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 S ATHERTON ST SUITE 2
STATE COLLEGE PA
16801-8324
US

IV. Provider business mailing address

3901 S ATHERTON ST SUITE 2
STATE COLLEGE PA
16801-8324
US

V. Phone/Fax

Practice location:
  • Phone: 814-466-2300
  • Fax: 814-466-2822
Mailing address:
  • Phone: 814-466-2300
  • Fax: 814-466-2822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberMD030666E
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD030666E
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier30477
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerGEISINGER HEALTH PLAN
# 2
Identifier50047400
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerCAPITAL BLUE CROSS
# 3
Identifier0009667720004
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 4
IdentifierGL116265
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerHIGHMARK BLUE SHIELD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: