Provider Demographics
NPI:1396760625
Name:GLENN, WILLIAM D IV (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:D
Last Name:GLENN
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1245
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29116-1245
Mailing Address - Country:US
Mailing Address - Phone:803-395-4497
Mailing Address - Fax:
Practice Address - Street 1:5073 CAROLINA HWY
Practice Address - Street 2:
Practice Address - City:DENMARK
Practice Address - State:SC
Practice Address - Zip Code:29042-1679
Practice Address - Country:US
Practice Address - Phone:803-245-5144
Practice Address - Fax:803-245-6277
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19072207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC190723Medicaid
SC423818Medicare Oscar/Certification
SCSC21415742Medicare PIN
SC190723Medicaid
SC5677Medicare PIN