Provider Demographics
NPI:1093769804
Name:GLENN, GEORGE CHESTER III (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:CHESTER
Last Name:GLENN
Suffix:III
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 1:1 INDEPENDENCE PT
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4545
Mailing Address - Country:US
Mailing Address - Phone:864-797-6044
Mailing Address - Fax:
Practice Address - Street 1:1686 SKYLAND DRIVE
Practice Address - Street 2:SUITE 201
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307
Practice Address - Country:US
Practice Address - Phone:864-582-8135
Practice Address - Fax:864-573-9757
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13451208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC134517Medicaid
E34110Medicare UPIN
SCE341107951Medicare PIN
SCE341103640Medicare PIN
SC134517Medicaid