Basic Information
| Provider Information | |||||||||
| NPI: | 1649218835 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KANE | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | I | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4419 | ||||||||
| Address2: | |||||||||
| City: | WOODLAND HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913654419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003589787 | ||||||||
| FaxNumber: | 8185872493 | ||||||||
| Practice Location | |||||||||
| Address1: | 1350 W COVINA BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN DIMAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917733245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095996811 | ||||||||
| FaxNumber: | 8185872493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 12/18/2008 | ||||||||
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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 | 207P00000X | G33423 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 930045580 | 01 | CA | RAILROAD MEDICARE | OTHER | 00G334230 | 01 | CA | BLUE SHIELD | OTHER | 00G334230 | 05 | CA | MEDICAID |