Basic Information
| Provider Information | |||||||||
| NPI: | 1689937260 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GLASS HEALTH PROGRAMS, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEDMARK TREATMENT CENTERS BELCAMP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1720 LAKEPOINTE DR STE 117 | ||||||||
| Address2: | |||||||||
| City: | LEWISVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750576425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143793300 | ||||||||
| FaxNumber: | 2148539018 | ||||||||
| Practice Location | |||||||||
| Address1: | 1361 BRASS MILL RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | BEL CAMP | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102739700 | ||||||||
| FaxNumber: | 4102739713 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2012 | ||||||||
| LastUpdateDate: | 04/20/2022 | ||||||||
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| AuthorizedOfficialLastName: | D'ANDRIA | ||||||||
| AuthorizedOfficialFirstName: | GENCO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2143793300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 101202 | MD | N | Agencies | Community/Behavioral Health | 261QM2800X | MD | N | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic | 261QR0405X | MD | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 905637 | 01 | MD | LICENSE | OTHER | 0019661780001 | 05 | PA | MEDICAID | 403453800 | 05 | MD | MEDICAID | 39191306 | 05 | MD | MEDICAID |