Provider Demographics
NPI:1275505794
Name:SMITH, GLENN R (PA-C)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:R
Last Name:SMITH
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Gender:M
Credentials:PA-C
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Mailing Address - Street 1:2100 STANTONSBURG RD
Mailing Address - Street 2:PO BOX 6028
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-2818
Mailing Address - Country:US
Mailing Address - Phone:252-847-4299
Mailing Address - Fax:252-874-8208
Practice Address - Street 1:BRODY OUTPATIENT CENTER
Practice Address - Street 2:600 MOYE BLVD
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858
Practice Address - Country:US
Practice Address - Phone:252-744-2207
Practice Address - Fax:252-744-3794
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2022-01-08
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Provider Licenses
StateLicense IDTaxonomies
NC104089363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ27016Medicare UPIN
NC2761770Medicare ID - Type Unspecified