Provider Demographics
NPI:1649300393
Name:MAPLE GLEN MEDICAL ASSOC
Entity type:Organization
Organization Name:MAPLE GLEN MEDICAL ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:A
Authorized Official - Last Name:HYATT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-646-0165
Mailing Address - Street 1:1000 E WELSH RD
Mailing Address - Street 2:
Mailing Address - City:AMBLER
Mailing Address - State:PA
Mailing Address - Zip Code:19002
Mailing Address - Country:US
Mailing Address - Phone:215-646-0165
Mailing Address - Fax:215-646-6104
Practice Address - Street 1:1000 E WELSH RD
Practice Address - Street 2:
Practice Address - City:AMBLER
Practice Address - State:PA
Practice Address - Zip Code:19002
Practice Address - Country:US
Practice Address - Phone:215-646-0165
Practice Address - Fax:215-646-6104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS008558L207R00000X
PASP009090207R00000X
PAMD023298E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty