Basic Information
| Provider Information | |||||||||
| NPI: | 1780662262 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BACON | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3998 FAIR RIDGE DR | ||||||||
| Address2: | STE 300 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220332921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032959360 | ||||||||
| FaxNumber: | 7037669725 | ||||||||
| Practice Location | |||||||||
| Address1: | 789 CENTRAL AVE | ||||||||
| Address2: | WENTWORTH DOUGLASS HOSPITAL | ||||||||
| City: | DOVER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037497246 | ||||||||
| FaxNumber: | 6037492453 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2006 | ||||||||
| LastUpdateDate: | 03/06/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 9896 | NH | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 30220036 | 05 | NH | MEDICAID |