Basic Information
| Provider Information | |||||||||
| NPI: | 1952619975 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PROVIDENCE | ||||||||
| FirstName: | GLEN | ||||||||
| MiddleName: | KENNETH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 SHENANGO AVE | ||||||||
| Address2: | |||||||||
| City: | SHARON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 161461503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7243426604 | ||||||||
| FaxNumber: | 7243421601 | ||||||||
| Practice Location | |||||||||
| Address1: | 197 E SILVER ST | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | SHARON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 161462186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7243426604 | ||||||||
| FaxNumber: | 7243421601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2010 | ||||||||
| LastUpdateDate: | 12/11/2013 | ||||||||
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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 | 207R00000X | MD443812 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1026452400001 | 05 | PA | MEDICAID | 0059701 | 05 | OH | MEDICAID | P010166 | 01 | PA | GATEWAY | OTHER |