Provider Demographics
NPI:1740294925
Name:GLENN, MARK DWIGHT (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:DWIGHT
Last Name:GLENN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3381 PHILLIS BLVD
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-1560
Mailing Address - Country:US
Mailing Address - Phone:843-477-0177
Mailing Address - Fax:843-839-1791
Practice Address - Street 1:3381 PHILLIS BLVD
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-1560
Practice Address - Country:US
Practice Address - Phone:843-477-0177
Practice Address - Fax:843-839-1791
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2015-09-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
SC138112084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCC84083Medicare UPIN