Basic Information
| Provider Information | |||||||||
| NPI: | 1174502140 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OGRADY | ||||||||
| FirstName: | GLENNON | ||||||||
| MiddleName: | JOHN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 DORCHESTER AVENUE | ||||||||
| Address2: | FAMILY MEDICINE | ||||||||
| City: | DORCHESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175064970 | ||||||||
| FaxNumber: | 9786864137 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 DORCHESTER AVENUE | ||||||||
| Address2: | FAMILY MEDICINE | ||||||||
| City: | DORCHESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175064970 | ||||||||
| FaxNumber: | 9786864137 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 03/23/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 59292 | MA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.