Provider Demographics
NPI:1588660716
Name:PERRY, GLENN BRADFORD (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:BRADFORD
Last Name:PERRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-358-0308
Mailing Address - Fax:704-358-0039
Practice Address - Street 1:2826 RANDOLPH RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1019
Practice Address - Country:US
Practice Address - Phone:704-358-0308
Practice Address - Fax:704-358-0039
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC26968207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8966884Medicaid
NC8966884Medicaid
209522PMedicare PIN