Basic Information
Provider Information | |||||||||
NPI: | 1447241989 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ANDERSEN | ||||||||
FirstName: | GLENNA | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 37174 | ||||||||
Address2: |   | ||||||||
City: | BALTIMORE | ||||||||
State: | MD | ||||||||
PostalCode: | 212973174 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5714235699 | ||||||||
FaxNumber: | 5714235698 | ||||||||
Practice Location | |||||||||
Address1: | 8501 ARLINGTON BLVD | ||||||||
Address2: | STE 300 | ||||||||
City: | FAIRFAX | ||||||||
State: | VA | ||||||||
PostalCode: | 220314617 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7035601612 | ||||||||
FaxNumber: | 7035730217 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/03/2005 | ||||||||
LastUpdateDate: | 10/19/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/19/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 0101038435 | VA | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 540894297 | 01 |   | PHCS | OTHER | 0919870001 | 01 |   | CIGNA | OTHER | 240947 | 01 |   | MDIPA/OPTIMUM | OTHER | 468150 | 01 |   | AETNA HMO | OTHER | 502418 | 01 |   | NCPPO | OTHER | 6254110 | 05 | VA |   | MEDICAID | AW3247005 | 01 |   | DEA | OTHER | 0700360 | 01 |   | UNHC | OTHER | 34300003 | 01 |   | BCBS OF DC | OTHER | 440156 | 01 |   | ANTHEM | OTHER | 540894297 | 01 |   | GW-ONE HEALTH | OTHER | 4204387 | 01 |   | AETNA | OTHER | 240947 | 01 |   | ALLIANCE | OTHER | 540894297 | 01 |   | MAIL HANDLERS | OTHER | 0101038435 | 01 |   | VA LICENSE | OTHER | 49D0861486 | 01 |   | CLIA | OTHER |