Provider Demographics
NPI:1770744989
Name:BANEGURA, GLENN (MD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:
Last Name:BANEGURA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 ROCKBRIDGE RD NW STE 172-121
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-8225
Mailing Address - Country:US
Mailing Address - Phone:617-901-6120
Mailing Address - Fax:
Practice Address - Street 1:400 PALMETTO HEALTH PKWY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-1760
Practice Address - Country:US
Practice Address - Phone:617-901-6120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-19
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN67897207R00000X
MS25734207R00000X
NV23114207R00000X
LA334379207R00000X
GA66752207R00000X
WI1796320207R00000X
IL036147581207R00000X
SC34002207R00000X
OH35C.000288207R00000X
MT129782208M00000X
HI16816207R00000X
AL31509207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC340027Medicaid
SCSCB3975019OtherMEDICARE PIN
SCSCB3979068OtherMEDICARE PIN