Basic Information
| Provider Information | |||||||||
| NPI: | 1164469177 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SCARBROUGH | ||||||||
| FirstName: | GLEN | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5353 REYNOLDS ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314056015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123556005 | ||||||||
| FaxNumber: | 9123555643 | ||||||||
| Practice Location | |||||||||
| Address1: | 5353 REYNOLDS ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314056015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123556005 | ||||||||
| FaxNumber: | 9123555643 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 02/10/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 044329 | GA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 00878215A | 05 | GA | MEDICAID | GA1133 | 05 | SC | MEDICAID |