Provider Demographics
NPI:1245297811
Name:MACNICHOL, GLENN EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:EDWARD
Last Name:MACNICHOL
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:110 PATRICK CT
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-1743
Mailing Address - Country:US
Mailing Address - Phone:252-443-0400
Mailing Address - Fax:252-443-0572
Practice Address - Street 1:110 PATRICK CT
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-1743
Practice Address - Country:US
Practice Address - Phone:252-443-0400
Practice Address - Fax:252-443-0572
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC34389207L00000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7953696Medicaid
NCE91126Medicare UPIN
NC2161309Medicare ID - Type Unspecified