NPIMap

Organization Active NPI

Marcia J Glenn MD & Associates Dermatology & Laser Med Ctr Inc

  • Dermatology Physician
  • Marina del Rey, CA
National Provider Identifier
1396984423
Registry record updated Oct 26, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
License
G63373 Issued in CA
Legal business name
MARCIA J GLENN MD & ASSOCIATES DERMATOLOGY & LASER MED CTR INC
Practice address
4644 Lincoln Blvd Ste 500
Marina del Rey, CA 90292-6391
Phone
(310) 821-7658
Fax
(310) 301-1783
NPI assigned
Feb 12, 2009
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 26, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Marcia J Glenn, M.D.NPI 1780731976
Title
President
Phone
(310) 821-7658

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207N00000X G63373 CA Primary
Pediatric Dermatology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207NP0225X G63373 CA

Addresses

Primary practice location

4644 Lincoln Blvd Ste 500
Marina del Rey, CA 90292-6391

Mailing address

4644 Lincoln Blvd Ste 500
Marina del Rey, CA 90292-6391
Phone (310) 821-7658

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050216000291 CA Part B Supplier - Clinic/Group Practice 1951353150 Receives reassigned benefits from 1 practitioner
Practice locations: Inglewood, CA

National Provider Directory

National Provider Directory

Networks

  • BSC 65 PLUS INDIVIDUAL MAPDPlans: Blue Shield 65 Plus (HMO) (H0504-015-000, H0504); Blue Shield 65 Plus (HMO) (H0504-039-000, H0504); Blue Shield 65 Plus Plan 2 (HMO) (H0504-021-000, H0504); Blue Shield Inspire (HMO) (H0504-041-000, H0504); Blue Shield 65 Plus (HMO) (H0504-038-000, H0504); Blue Shield Inspire (HMO) (H0504-047-000, H0504); Blue Shield 65 Plus (HMO) (H0504-026-000, H0504); Blue Shield Advantage (HMO) (H0504-050-000, H0504); Blue Shield AdvantageOptimum Plan (HMO) (H5928-004-000, H5928); Blue Shield Inspire (HMO) (H0504-043-000, H0504)…

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1234396800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1540512000000",
    "number": "1396984423",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4644 LINCOLN BLVD STE 500",
            "city": "MARINA DEL REY",
            "state": "CA",
            "postal_code": "902926391",
            "telephone_number": "310-821-7658",
            "fax_number": "310-821-1708"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4644 LINCOLN BLVD STE 500",
            "city": "MARINA DEL REY",
            "state": "CA",
            "postal_code": "902926391",
            "telephone_number": "310-821-7658",
            "fax_number": "310-301-1783"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MARCIA J GLENN MD & ASSOCIATES DERMATOLOGY & LASER MED CTR INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-02-12",
        "last_updated": "2018-10-26",
        "status": "A",
        "authorized_official_last_name": "GLENN",
        "authorized_official_first_name": "MARCIA",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "310-821-7658",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dermatology",
            "state": "CA",
            "license": "G63373",
            "primary": true
        },
        {
            "code": "207NP0225X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dermatology, Pediatric Dermatology",
            "state": "CA",
            "license": "G63373",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Marina del Rey, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 26, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.