Provider Demographics
NPI:1992707350
Name:HAMM, GLENN GORDON (MD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:GORDON
Last Name:HAMM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3512 STATE ROUTE 257 STE 108
Mailing Address - Street 2:
Mailing Address - City:SENECA
Mailing Address - State:PA
Mailing Address - Zip Code:16346-2946
Mailing Address - Country:US
Mailing Address - Phone:814-677-3717
Mailing Address - Fax:814-677-8914
Practice Address - Street 1:3512 STATE ROUTE 257
Practice Address - Street 2:SUITE 106
Practice Address - City:SENECA
Practice Address - State:PA
Practice Address - Zip Code:16346-2946
Practice Address - Country:US
Practice Address - Phone:814-677-3717
Practice Address - Fax:814-677-8914
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD029612E208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010113300004Medicaid
PAMD029612EOtherMEDICAL LICENSE
PA0010113300004Medicaid