Provider Demographics
NPI:1366560229
Name:GLASSON SPORTS MEDICINE PC
Entity type:Organization
Organization Name:GLASSON SPORTS MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:ELISE
Authorized Official - Last Name:GLASSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-412-1005
Mailing Address - Street 1:PO BOX 844560
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-4560
Mailing Address - Country:US
Mailing Address - Phone:757-412-1005
Mailing Address - Fax:757-412-1010
Practice Address - Street 1:968 FIRST COLONIAL RD
Practice Address - Street 2:SUITE 101
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-3171
Practice Address - Country:US
Practice Address - Phone:757-412-1005
Practice Address - Fax:757-412-1015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6409351Medicaid
VAF39936Medicare UPIN
VA6409351Medicaid
VA4975470001Medicare NSC