Provider Demographics
NPI:1912972449
Name:LUBASH, GLENN D (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:D
Last Name:LUBASH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1350
Mailing Address - Street 2:SUITE 5
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115-1350
Mailing Address - Country:US
Mailing Address - Phone:707-799-3380
Mailing Address - Fax:704-799-6315
Practice Address - Street 1:171 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-9500
Practice Address - Country:US
Practice Address - Phone:704-660-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207RN0300X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89134Y1Medicaid
NCC97942Medicare UPIN
NC89134Y1Medicaid