Provider Demographics
NPI:1033170972
Name:RANDALL, GLENN R (MD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:R
Last Name:RANDALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:277 EAST MOUNTAIN ST
Mailing Address - Street 2:SUMMIT ELDERCARE
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606
Mailing Address - Country:US
Mailing Address - Phone:508-852-2026
Mailing Address - Fax:508-856-7130
Practice Address - Street 1:277 EAST MOUNTAIN ST
Practice Address - Street 2:SUMMIT ELDERCARE
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01606
Practice Address - Country:US
Practice Address - Phone:508-852-2026
Practice Address - Fax:508-856-7130
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA80026207R00000X, 207RG0300X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
J14922OtherBLUE SHIELD INDEMNITY
J14922OtherMEDICARE B
110175052OtherRAILROAD MEDICARE
27190OtherCHILDRENS MED SEC PLAN
27190OtherHEALTHY START
784073OtherMVP HEALTH CARE
J14922OtherBLUE CARE ELECT
J14922OtherBLUE SHIELD HMO BLUE
0400961OtherEVERCARE
042472266OtherHEALTHCARE VALUE MGMT
1061182OtherFIRST HEALTH
MA3131335Medicaid
042472266OtherONE HEALTH PLAN
042472266OtherPRIVATE HEALTHCARE SYSTEM
6633909OtherCIGNA HEALTH PLAN
7001328OtherAETNA US HEALTHCARE
991122OtherFALLON COMMUNITY HEALTH P
AA2364OtherHARVARD PILGRIM HEALTHCAR
27190OtherCHILDRENS MED SEC PLAN
6633909OtherCIGNA HEALTH PLAN