Provider Demographics
NPI:1265656094
Name:FANDETTI, GLEN ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:ANTHONY
Last Name:FANDETTI
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 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 E W T HARRIS BLVD
Practice Address - Street 2:STE 1213
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-3485
Practice Address - Country:US
Practice Address - Phone:704-863-1950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2008-01700207R00000X, 207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1265656094Medicaid
NC5910546Medicaid
SCN01700Medicaid
NC2023098CMedicare PIN
NC2023098BMedicare PIN
RI007059615Medicare PIN
NC5910546Medicaid
NC2023098Medicare PIN
RIH88604Medicare UPIN
NC1265656094Medicaid
RIP00459684Medicare PIN
NCNCF480AMedicare PIN