Basic Information
| Provider Information | |||||||||
| NPI: | 1619939550 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOFSTROM | ||||||||
| FirstName: | GLEN | ||||||||
| MiddleName: | THEODORE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1201 GRAMPIAN BLVD | ||||||||
| Address2: | SUITE 1K | ||||||||
| City: | WILLIAMSPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 177011900 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 145 SHAFFER ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH WILLIAMSPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 177026727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703262447 | ||||||||
| FaxNumber: | 5703261247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2006 | ||||||||
| LastUpdateDate: | 10/20/2011 | ||||||||
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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 | MD019823E | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 544226 | 01 | PA | AETNA | OTHER | 001793 | 01 | PA | FIRST PRIORITY HEALTH | OTHER | B34545 | 01 | PA | HEALTHAMERICA | OTHER | 0010813260001 | 05 | PA | MEDICAID | 057619 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 1553395 | 01 | PA | UNITEDHEALTHCARE | OTHER |