Provider Demographics
NPI:1174697346
Name:MILLER, GLENN (MD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:
Last Name:MILLER
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 1:3831 RAMAGE RUN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGDON VALLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19006-2453
Mailing Address - Country:US
Mailing Address - Phone:215-938-0254
Mailing Address - Fax:
Practice Address - Street 1:2410 S BROAD ST
Practice Address - Street 2:3RD FLR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-4418
Practice Address - Country:US
Practice Address - Phone:215-462-6600
Practice Address - Fax:215-462-2650
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD033553E207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ20033920OtherAMERIHEALTH MERCY
PA050088759OtherRR MEDICARE
NJ30003770OtherHORIZON NJ HEALTH
PA011223020Medicaid
NJ517607OtherAMERIHEALTH ADMINISTRATOR
PA0112230205OtherALL IBC PRODUCTS
PA3039OtherBRAVO BY ELDER HEALTH
PA517607OtherALL BLUE SHIELD
NJ0111120000OtherAMERIHEALTH PC & HMO
PA2992866OtherAETNA
PA30003770OtherKEYSTONE MERCY
PA3039OtherBRAVO BY ELDER HEALTH
PA517607QL6Medicare ID - Type Unspecified