Provider Demographics
NPI:1629274956
Name:CHARLTON, GLENN BAKER (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:BAKER
Last Name:CHARLTON
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 1:2418 JILLIAN LN
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:PA
Mailing Address - Zip Code:16148-7728
Mailing Address - Country:US
Mailing Address - Phone:919-724-9539
Mailing Address - Fax:724-591-8909
Practice Address - Street 1:2962 E STATE ST
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:PA
Practice Address - Zip Code:16148-2757
Practice Address - Country:US
Practice Address - Phone:724-777-1895
Practice Address - Fax:724-591-8909
Is Sole Proprietor?:No
Enumeration Date:2007-06-24
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200701478207P00000X
TXM5097207P00000X
PAMD019961E207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC146GAOtherBCBS OF NC
NC5907696Medicaid
PA000549072Medicaid
PA000549072Medicaid
PA091201RN0Medicare PIN