Basic Information
Provider Information
NPI: 1396001798
EntityType: 2
ReplacementNPI:  
OrganizationName: GLASS HEALTH PROGRAMS, INC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: MEDMARK TREATMENT CENTERS -BALTIMORE DOWNTOWN 201
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1720 LAKEPOINTE DR STE 117
Address2:  
City: LEWISVILLE
State: TX
PostalCode: 750576425
CountryCode: US
TelephoneNumber: 2143793300
FaxNumber: 2148539018
Practice Location
Address1: 821 N EUTAW ST ST
Address2: SUITE 201
City: BALTIMORE
State: MD
PostalCode: 21201
CountryCode: US
TelephoneNumber: 4102259185
FaxNumber: 4102257964
Other Information
ProviderEnumerationDate: 04/10/2012
LastUpdateDate: 04/20/2022
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: D'ANDRIA
AuthorizedOfficialFirstName: GENCO
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: CFO
AuthorizedOfficialTelephone: 2143793300
IsSoleProprietor:  
IsOrganizationSubpart: Y
ParentOrganizationLBN: GLASS HEALTH PROGRAM, INC
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 04/20/2022

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QR0405X904787MDN Ambulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
261QM2800X905634MDY Ambulatory Health Care FacilitiesClinic/CenterMethadone Clinic

ID Information
IDTypeStateIssuerDescription
3919130105MD MEDICAID


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