Provider Demographics
NPI:1295864379
Name:KHEIREDDINE, GLENCORA (MD)
Entity Type:Individual
Prefix:
First Name:GLENCORA
Middle Name:
Last Name:KHEIREDDINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5950 FAIRVIEW RD STE 330
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-2108
Mailing Address - Country:US
Mailing Address - Phone:704-495-6334
Mailing Address - Fax:704-817-7219
Practice Address - Street 1:6060 PIEDMONT ROW DR S FL 7
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28287
Practice Address - Country:US
Practice Address - Phone:704-489-3094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC134019207R00000X
NC2009-00399207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN0039DMedicaid
NC5913167Medicaid
SCN0039DMedicaid