Provider Demographics
NPI:1437684453
Name:SPECIALTY ORTHOPAEDICS AND SPORTS MEDICINE, LLC
Entity Type:Organization
Organization Name:SPECIALTY ORTHOPAEDICS AND SPORTS MEDICINE, LLC
Other - Org Name:SPECORTHO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:T
Authorized Official - Last Name:FELTHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:570-452-0097
Mailing Address - Street 1:130 CRISANTO AVENUE
Mailing Address - Street 2:SUITE B
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715
Mailing Address - Country:US
Mailing Address - Phone:803-548-6464
Mailing Address - Fax:803-396-8440
Practice Address - Street 1:130 CRISANTO AVENUE
Practice Address - Street 2:SUITE B
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715
Practice Address - Country:US
Practice Address - Phone:803-548-6464
Practice Address - Fax:803-396-8440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-27
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG842Medicaid