Provider Demographics
NPI:1861509184
Name:FUSSELL, GLENN EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:EDWARD
Last Name:FUSSELL
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 1:2827 WARM SPRINGS RD
Mailing Address - Street 2:SUITE 3-B
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-5246
Mailing Address - Country:US
Mailing Address - Phone:706-324-4177
Mailing Address - Fax:
Practice Address - Street 1:2827 WARM SPRINGS RD
Practice Address - Street 2:SUITE 3-B
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-5246
Practice Address - Country:US
Practice Address - Phone:706-324-4177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA026777207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00330063CMedicaid
GA6485960001OtherNSC PTAN
GA08BDPHDMedicare ID - Type Unspecified
GA6485960001OtherNSC PTAN