Basic Information
| Provider Information | |||||||||
| NPI: | 1154789014 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GLASS HEALTH PROGRAMS, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1720 LAKEPOINTE DR STE 117 | ||||||||
| Address2: | |||||||||
| City: | LEWISVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750576425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143793300 | ||||||||
| FaxNumber: | 2148539018 | ||||||||
| Practice Location | |||||||||
| Address1: | 817 N CALVERT ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212023705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4432906424 | ||||||||
| FaxNumber: | 4105284509 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2016 | ||||||||
| LastUpdateDate: | 04/20/2022 | ||||||||
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| AuthorizedOfficialLastName: | D'ANDRIA | ||||||||
| AuthorizedOfficialFirstName: | GENCO | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2143793300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEDMARK SERVICES | ||||||||
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| NPICertificationDate: | 04/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
ID Information
| ID | Type | State | Issuer | Description | 906184 | 01 | MD | MD DHMH | OTHER |