Provider Demographics
NPI:1104160787
Name:GLASS, JERILYN KAY (MD)
Entity type:Individual
Prefix:DR
First Name:JERILYN
Middle Name:KAY
Last Name:GLASS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18510 BLACK KETTLE DR
Mailing Address - Street 2:
Mailing Address - City:BOYDS
Mailing Address - State:MD
Mailing Address - Zip Code:20841-4310
Mailing Address - Country:US
Mailing Address - Phone:301-515-1091
Mailing Address - Fax:
Practice Address - Street 1:18510 BLACK KETTLE DR
Practice Address - Street 2:
Practice Address - City:BOYDS
Practice Address - State:MD
Practice Address - Zip Code:20841-4310
Practice Address - Country:US
Practice Address - Phone:301-515-1091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0042957207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery