MEDICARE: MR. GERALD GILBERT GLASS PA

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	363AM0700X	Medical Physician Assistant	PA3172	FL

General Provider Information

NPI Number	:	1871996942
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GERALD GILBERT GLASS PA

Provider Business Mailing Address
First Line	:	2901 SW 149TH AVE
Second Line	:	SUITE 400
City	:	MIRAMAR
State	:	FL
Zip	:	33027-4151
Country	:	US
Telephone Number	:	954-874-4603
Fax Number	:	954-874-3261

Provider Business Practice Location Address
First Line	:	2901 SW 149TH AVE
Second Line	:	SUITE 400
City	:	MIRAMAR
State	:	FL
Zip	:	33027-4151
Country	:	US
Telephone Number	:	954-874-4603
Fax Number	:	954-874-3261

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

Provider Enumeration Date	:	10/03/2014
Last Update Date	:	10/03/2014

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