Provider Demographics
NPI:1730133596
Name:GLACE, CHARLES LAWRENCE (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:LAWRENCE
Last Name:GLACE
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 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:2995 REIDVILLE RD STE 210
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-5631
Practice Address - Country:US
Practice Address - Phone:864-253-8140
Practice Address - Fax:864-587-0051
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC13363207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC133634Medicaid
SCSCE4635019OtherMEDICARE PIN
SC5878670013Medicare NSC
D17669Medicare UPIN