MEDICARE: DR. GLENN HOWARD PISK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080A0000X	Pediatric Adolescent Medicine Physician	MD0411084L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114971066
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GLENN HOWARD PISK M.D.

Provider Business Mailing Address
First Line	:	2129 W OREGON AVE
Second Line	:	FIRST FLOOR REAR
City	:	PHILADELPHIA
State	:	PA
Zip	:	19145-4131
Country	:	US
Telephone Number	:	215-462-6106
Fax Number	:	215-462-5922

Provider Business Practice Location Address
First Line	:	2129 W OREGON AVE
Second Line	:	FIRST FLOOR REAR
City	:	PHILADELPHIA
State	:	PA
Zip	:	19145-4131
Country	:	US
Telephone Number	:	215-462-6106
Fax Number	:	215-462-5922

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/22/2006
Last Update Date	:	07/11/2013

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