MEDICARE: GLENSIDE MEDICAL ASSOCIATES, LLC

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1215936901
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLENSIDE MEDICAL ASSOCIATES, LLC

Provider Business Mailing Address
First Line	:	4000A GLENSIDE DR
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23228-4102
Country	:	US
Telephone Number	:	804-262-4763
Fax Number	:	804-264-9683

Provider Business Practice Location Address
First Line	:	4000A GLENSIDE DR
Second Line	:
City	:	RICHMOND
State	:	VA
Zip	:	23228-4102
Country	:	US
Telephone Number	:	804-262-4763
Fax Number	:	804-264-9683

Authorized Official
Title or Position	:	SR DIRECTOR, ENTERPRISE REVENUE CYC
Name	:	ROBIN CAMPBELL
Credential	:
Telephone Number	:	804-262-4763

Provider Enumeration Date	:	07/15/2005
Last Update Date	:	09/22/2023

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