Provider Demographics
NPI:1306819578
Name:CUMBUS, GLEN (PT)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:CUMBUS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 GROVE RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-4630
Mailing Address - Country:US
Mailing Address - Phone:864-370-9211
Mailing Address - Fax:864-370-9290
Practice Address - Street 1:1007 GROVE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4630
Practice Address - Country:US
Practice Address - Phone:864-370-9211
Practice Address - Fax:864-370-9290
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3681225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP95520Medicare UPIN