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General NPI Number Information
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NPI Number | 1093897142
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Entity Type | Organization
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Legal Business Name | GLEN MEDICAL HEALTH, PC
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Dates
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Enumeration Date | 10/19/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 154 FOREST AVE
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City | GLEN COVE
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State | NY
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Zip | 11542-2023
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Country | US
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Telephone | 516-759-5005
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Fax | 516-759-1509
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Provider Business Mailing Address
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Address Line | 154 FOREST AVE
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City | GLEN COVE
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State | NY
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Zip | 11542-2023
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Country | US
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Telephone | 516-759-5005
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Fax | 516-759-1509
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Authorized Official
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Title or Position | PRESIDENT
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Name | LORETTA M SIEGEL
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Credential | M.D.
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Telephone | 516-759-5005
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 176195
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License Number State | NY
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