Basic Information
| Provider Information | |||||||||
| NPI: | 1033117437 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GANDELMAN | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 81 HOLLY HILL LN FL 3 | ||||||||
| Address2: | |||||||||
| City: | GREENWICH | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068306071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2038695515 | ||||||||
| FaxNumber: | 2038695765 | ||||||||
| Practice Location | |||||||||
| Address1: | 81 HOLLY HILL LN FL 3 | ||||||||
| Address2: | |||||||||
| City: | GREENWICH | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068306071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2038695515 | ||||||||
| FaxNumber: | 2038695765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2005 | ||||||||
| LastUpdateDate: | 12/06/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 218641 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 174400000X | 218641 | NY | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 02646115 | 05 | NY | MEDICAID |