Provider Demographics
NPI:1083704175
Name:QUATTLEBAUM, ROBERT GLEN (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:GLEN
Last Name:QUATTLEBAUM
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:PO BOX 100174
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-3174
Mailing Address - Country:US
Mailing Address - Phone:864-512-7257
Mailing Address - Fax:864-654-3261
Practice Address - Street 1:885 TIGER BLVD
Practice Address - Street 2:
Practice Address - City:CLEMSON
Practice Address - State:SC
Practice Address - Zip Code:29631-1480
Practice Address - Country:US
Practice Address - Phone:864-512-7257
Practice Address - Fax:864-654-3261
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27937207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00638301OtherRAILROAD MEDICARE ID
SC279371Medicaid
SCP00638301OtherRAILROAD MEDICARE ID
SCAA2959Medicare UPIN