Provider Demographics
NPI:1417928474
Name:FUSONIE, GLENN E (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:E
Last Name:FUSONIE
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 1:5 FIRST VILLAGE DR
Mailing Address - Street 2:PO BOX 2000
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374
Mailing Address - Country:US
Mailing Address - Phone:910-295-6831
Mailing Address - Fax:910-295-0244
Practice Address - Street 1:5 FIRST VILLAGE DR
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-9495
Practice Address - Country:US
Practice Address - Phone:910-295-6831
Practice Address - Fax:910-295-0244
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH120602086S0129X
NC2018-003272086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH384134OtherMVP
NH3350708OtherAETNA
NH7252896OtherCIGNA
NHAA1999OtherHARVARD PILGRIM HLTHCARE
NH30203855Medicaid
NH01Y005238NH01OtherANTHEM
NHAA1999OtherHARVARD PILGRIM HLTHCARE
NH30203855Medicaid