Basic Information
| Provider Information | |||||||||
| NPI: | 1013963305 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OB/GYN @ TREXLERTOWN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1650 VALLEY CENTER PKWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BETHLEHEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180172344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4848844436 | ||||||||
| FaxNumber: | 4848844444 | ||||||||
| Practice Location | |||||||||
| Address1: | 6900 HAMILTON BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | TREXLERTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 18087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104020170 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GLAZERMAN | ||||||||
| AuthorizedOfficialFirstName: | LARRY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6104020170 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 570721 | 01 | PA | AMERIHEALTH ADM | OTHER | 570721 | 01 | PA | KEYSTONE CENTRAL | OTHER | 5889774 | 01 | PA | AETNA PPO | OTHER | 2145774 | 01 | PA | AETNA HMO | OTHER | 570721 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 02348600 | 01 | PA | CAPITAL | OTHER |