Healthcare Provider Details

I. General information

NPI: 1528025640
Provider Name (Legal Business Name): GLENN CROTTY JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 11/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 MORRIS ST
CHARLESTON WV
25301-1326
US

IV. Provider business mailing address

PO BOX 1320
SAINT ALBANS WV
25177-1320
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-7647
  • Fax: 304-388-7696
Mailing address:
  • Phone: 304-388-1724
  • Fax: 304-388-1721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number10877
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: