Provider Demographics
NPI:1407904493
Name:GLEN, JONATHAN COLEMAN (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:COLEMAN
Last Name:GLEN
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 1:721 OKATIE HWY # 170
Mailing Address - Street 2:
Mailing Address - City:OKATIE
Mailing Address - State:SC
Mailing Address - Zip Code:29909-3963
Mailing Address - Country:US
Mailing Address - Phone:843-987-7400
Mailing Address - Fax:
Practice Address - Street 1:716 E 71ST ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-4907
Practice Address - Country:US
Practice Address - Phone:912-355-1533
Practice Address - Fax:912-355-5984
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA21984174400000X
SC7816207RG0100X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No174400000XOther Service ProvidersSpecialist
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00234429AMedicaid
SCG07186Medicaid