Provider Demographics
NPI:1154548030
Name:GLENN WOOD MD PA
Entity type:Organization
Organization Name:GLENN WOOD MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:G
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-341-9707
Mailing Address - Street 1:2000 N MAYS ST
Mailing Address - Street 2:STE 109
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-2166
Mailing Address - Country:US
Mailing Address - Phone:512-341-9707
Mailing Address - Fax:512-374-9702
Practice Address - Street 1:2000 N MAYS ST
Practice Address - Street 2:STE 109
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-2166
Practice Address - Country:US
Practice Address - Phone:512-341-9707
Practice Address - Fax:512-374-9702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX153715104Medicaid
TX153715103Medicaid