Healthcare Provider Details

I. General information

NPI: 1457652703
Provider Name (Legal Business Name): GLENN WOOD MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2010
Last Update Date: 11/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2621 RIDGEPOINT DR SUITE 130
AUSTIN TX
78754-5232
US

IV. Provider business mailing address

9411 N LAMAR BLVD
AUSTIN TX
78753-4178
US

V. Phone/Fax

Practice location:
  • Phone: 512-583-9600
  • Fax:
Mailing address:
  • Phone: 512-977-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberK4012
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number558670000
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: GLENN WOOD
Title or Position: OWNER
Credential: MD
Phone: 512-583-9600