Provider Demographics
NPI:1104605377
Name:GLEE MED SPA
Entity type:Organization
Organization Name:GLEE MED SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHOSHANA
Authorized Official - Middle Name:
Authorized Official - Last Name:NOURMAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-419-9984
Mailing Address - Street 1:6510 GARDENWICK RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-2538
Mailing Address - Country:US
Mailing Address - Phone:410-419-9984
Mailing Address - Fax:
Practice Address - Street 1:2219 YORK RD STE 103
Practice Address - Street 2:
Practice Address - City:TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-3140
Practice Address - Country:US
Practice Address - Phone:410-826-0800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes202D00000XAllopathic & Osteopathic PhysiciansIntegrative MedicineGroup - Single Specialty