Provider Demographics
NPI:1528018645
Name:ROBISON, GLEN A (CH)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:A
Last Name:ROBISON
Suffix:
Gender:M
Credentials:CH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 FOLLY ROAD
Mailing Address - Street 2:STE H
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-2507
Mailing Address - Country:US
Mailing Address - Phone:843-795-2575
Mailing Address - Fax:843-762-4891
Practice Address - Street 1:325 FOLLY ROAD
Practice Address - Street 2:STE H
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-2507
Practice Address - Country:US
Practice Address - Phone:843-795-2575
Practice Address - Fax:843-762-4891
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1224111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH1226Medicaid
SCCH1226Medicaid
SCQ269213811Medicare PIN