Provider Demographics
NPI:1487741757
Name:BOMBARDIER, GLEN P (MD)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:P
Last Name:BOMBARDIER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 HOSPITAL DRIVE
Mailing Address - Street 2:SUITE 308
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01040-6603
Mailing Address - Country:US
Mailing Address - Phone:413-533-7139
Mailing Address - Fax:413-533-2901
Practice Address - Street 1:10 HOSPITAL DRIVE
Practice Address - Street 2:SUITE 308
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-6603
Practice Address - Country:US
Practice Address - Phone:413-533-7139
Practice Address - Fax:413-533-2901
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA45861207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0133345Medicaid
MA0133345Medicaid
B97642Medicare UPIN