Provider Demographics
NPI:1275612335
Name:BECKNER, GLEN ERIC (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:ERIC
Last Name:BECKNER
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 65598
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28265-0598
Mailing Address - Country:US
Mailing Address - Phone:843-881-4325
Mailing Address - Fax:
Practice Address - Street 1:1200 JOHNNIE DODDS BLVD
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3231
Practice Address - Country:US
Practice Address - Phone:843-881-4325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20382207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT42309Medicaid
SCG550887070Medicare PIN
SCP00223885Medicare PIN
SCT42309Medicaid