Provider Demographics
NPI:1740281567
Name:GRIDER, GLENNA LEA (MD)
Entity type:Individual
Prefix:
First Name:GLENNA
Middle Name:LEA
Last Name:GRIDER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 PAGE RD
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-8798
Mailing Address - Country:US
Mailing Address - Phone:919-774-6518
Mailing Address - Fax:919-774-1831
Practice Address - Street 1:555 CARTHAGE ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-4104
Practice Address - Country:US
Practice Address - Phone:919-774-6518
Practice Address - Fax:919-774-1831
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005 00569207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1396JOtherBC/BS NC
NC5901059Medicaid
NCFH1100110OtherFIRSTCAROLINACARE
P00869141OtherRAILROAD MEDICARE PTAN
NC1396JOtherBC/BS NC
NCFH1100110OtherFIRSTCAROLINACARE