Active NPI
Glen Theodore Hofstrom, MD
- Family Medicine Physician
- South Williamsport, PA
National Provider Identifier
1619939550
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- MD019823E
- Practice address
- 145 Shaffer St
South Williamsport, PA 17702-6727 - Phone
- (570) 326-2447
- Fax
- (570) 326-1247
- NPI assigned
- Apr 5, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | MD019823E | PA | Primary |
Addresses
Primary practice location
145 Shaffer St
South Williamsport, PA 17702-6727
Mailing address
1201 Grampian Blvd
Suite 1K
Williamsport, PA 17701-1900
Other identifiers 6
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 544226 | Other | PA | AETNA |
| 001793 | Other | PA | FIRST PRIORITY HEALTH |
| B34545 | Other | PA | HEALTHAMERICA |
| 0010813260001 | Medicaid | PA | |
| 057619 | Other | PA | HIGHMARK BLUE SHIELD |
| 1553395 | Other | PA | UNITEDHEALTHCARE |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1144195200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1319068800000",
"number": "1619939550",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1201 GRAMPIAN BLVD",
"address_2": "SUITE 1K",
"city": "WILLIAMSPORT",
"state": "PA",
"postal_code": "177011900"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "145 SHAFFER ST",
"city": "SOUTH WILLIAMSPORT",
"state": "PA",
"postal_code": "177026727",
"telephone_number": "570-326-2447",
"fax_number": "570-326-1247"
}
],
"practiceLocations": [],
"basic": {
"last_name": "HOFSTROM",
"first_name": "GLEN",
"middle_name": "THEODORE",
"name_prefix": "Dr.",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-04-05",
"last_updated": "2011-10-20",
"status": "A"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "PA",
"license": "MD019823E",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "AETNA",
"identifier": "544226",
"state": "PA"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "FIRST PRIORITY HEALTH",
"identifier": "001793",
"state": "PA"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "HEALTHAMERICA",
"identifier": "B34545",
"state": "PA"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "0010813260001",
"state": "PA"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "HIGHMARK BLUE SHIELD",
"identifier": "057619",
"state": "PA"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "UNITEDHEALTHCARE",
"identifier": "1553395",
"state": "PA"
}
],
"endpoints": [],
"other_names": []
}Other providers in South Williamsport, PA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 20, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.