Basic Information
Provider Information | |||||||||
NPI: | 1457302820 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FLORES | ||||||||
FirstName: | GLENN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | CONNECTICUT CHILDREN'S SPECIALTY GROUP | ||||||||
Address2: | 60 HARTLAND STREET - CBO | ||||||||
City: | EAST HARTFORD | ||||||||
State: | CT | ||||||||
PostalCode: | 061083250 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8608375602 | ||||||||
FaxNumber: | 8608375613 | ||||||||
Practice Location | |||||||||
Address1: | CONNECTICUT CHILDREN'S SPECIALTY GROUP | ||||||||
Address2: | 282 WASHINGTON STREET | ||||||||
City: | HARTFORD | ||||||||
State: | CT | ||||||||
PostalCode: | 061063322 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8608377250 | ||||||||
FaxNumber: | 8608377251 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/12/2006 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 45006 | WI | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208000000X | 33074 | CT | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 1457302820 | 05 | CT |   | MEDICAID | 34250700 | 05 | WI |   | MEDICAID | 008000261B | 01 |   | HUMANA | OTHER |