Provider Demographics
NPI:1043248727
Name:EHRESMANN, GLENN (MD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:
Last Name:EHRESMANN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-5100
Mailing Address - Fax:
Practice Address - Street 1:1520 SAN PABLO ST
Practice Address - Street 2:SUITE 1000
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5310
Practice Address - Country:US
Practice Address - Phone:323-442-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG27348207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA110062903OtherRAILROAD MEDICARE
CA00G273480Medicaid
CA00G273480OtherBLUE SHILED
CAGR0016910OtherGROUP MEDICAID PIN
CA1902846306OtherGROUP NPI
CAGR0100430OtherGROUP MEDICAL
CACE1617OtherGROUP RAILROAD MEDICARE
CAW18762OtherGROUP MEDICARE
CA1356930009OtherGROUP NPI
CAW11675OtherGROUP MEDICARE PIN
CA1356930009OtherGROUP NPI
CAWG27348AMedicare PIN