Provider Demographics
NPI:1336519560
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:CREDENTIALING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:KILCOLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-583-9679
Mailing Address - Street 1:9411 N LAMAR BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78753-4179
Mailing Address - Country:US
Mailing Address - Phone:512-583-9679
Mailing Address - Fax:512-233-0985
Practice Address - Street 1:7112 ED BLUESTEIN BLVD STE 100
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-2913
Practice Address - Country:US
Practice Address - Phone:512-744-6000
Practice Address - Fax:512-233-0985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty