Provider Demographics
NPI:1720077324
Name:HENRY, GLEN A (MD, FACC)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:A
Last Name:HENRY
Suffix:
Gender:M
Credentials:MD, FACC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:770-219-8840
Practice Address - Street 1:200 S ENOTA DR NE STE 200
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3466
Practice Address - Country:US
Practice Address - Phone:770-534-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT033328207RI0011X
GA033328207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT060050671OtherMEDICARE RAILROAD PIN
CT001333286Medicaid
CT060050671Medicare PIN
CT0600001218Medicare ID - Type Unspecified
CT060001218Medicare PIN
CT060001827Medicare PIN
G65617Medicare UPIN