Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NS0005X | Chiropractic Sports Physician | 708 | CT |
NPI | 1093826752 |
---|---|
Provider Name | Glenn Stewart Herman |
First Address | Naugatuck, CT 06770-2806 |
Second Address | Naugatuck, CT 06770-2806 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/08/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
004092508 | (05) | CT |
050000708CT01 | ANTHEM BLUE CROSS/BLUE SH (01) | CT |