MEDICARE: GLENN ERIC GIFFORD PA C

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	363A00000X	Physician Assistant	MA053012	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	13654471	OTHER		CAQH

General Provider Information

NPI Number	:	1205011475
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLENN ERIC GIFFORD PA C

Provider Business Mailing Address
First Line	:	970 FREEPORT RD
Second Line	:
City	:	PITTSBURGH
State	:	PA
Zip	:	15238-3100
Country	:	US
Telephone Number	:	412-325-5000
Fax Number	:	412-696-0381

Provider Business Practice Location Address
First Line	:	970 FREEPORT RD
Second Line	:
City	:	PITTSBURGH
State	:	PA
Zip	:	15238-3100
Country	:	US
Telephone Number	:	412-325-5000
Fax Number	:	412-696-0381

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

Provider Enumeration Date	:	01/07/2008
Last Update Date	:	10/08/2020

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Directions to “ GLENN ERIC GIFFORD PA C” Practice Location

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