Provider Demographics
NPI:1609941251
Name:MCKENNA, GLENN BENARD (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:BENARD
Last Name:MCKENNA
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 1:1116 PARKER PL NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324-5402
Mailing Address - Country:US
Mailing Address - Phone:404-931-7978
Mailing Address - Fax:
Practice Address - Street 1:800 N FANT ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-5708
Practice Address - Country:US
Practice Address - Phone:864-512-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC82260207P00000X
MI4301508615207P00000X
MO2017039490207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine