Provider Demographics
NPI:1447208459
Name:STAYER, GLENN A (MD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:A
Last Name:STAYER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:CREDENTIALS DEPT
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:
Practice Address - Street 1:100 N ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822-1405
Practice Address - Country:US
Practice Address - Phone:570-271-6012
Practice Address - Fax:570-271-9723
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD038769E208000000X, 2084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011660020001Medicaid
PA0011660020001Medicaid
PAST430068Medicare PIN