Individual
DR. GLEN KENNETH PROVIDENCE
Active
Individual
DR. GLEN KENNETH PROVIDENCE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
MD443812
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0059701
—
OH
05
—
1026452400001
—
PA
01
—
P010166
GATEWAY
PA
Enumeration date
09/24/2010
Last updated
12/11/2013
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