Healthcare Provider Details

I. General information

NPI: 1346474806
Provider Name (Legal Business Name): GLENN DYM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2009
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 MINISTRY PKWY
WESTON WI
54476-5220
US

IV. Provider business mailing address

483 N SEMORAN BLVD STE 102
WINTER PARK FL
32792-3800
US

V. Phone/Fax

Practice location:
  • Phone: 715-393-1000
  • Fax:
Mailing address:
  • Phone: 407-645-1847
  • Fax: 321-274-0246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number103868
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number257477
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: