Basic Information
| Provider Information | |||||||||
| NPI: | 1245297811 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MACNICHOL | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 PATRICK CT | ||||||||
| Address2: | |||||||||
| City: | ROCKY MOUNT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278041743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524430400 | ||||||||
| FaxNumber: | 2524430572 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 PATRICK CT | ||||||||
| Address2: | |||||||||
| City: | ROCKY MOUNT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278041743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524430400 | ||||||||
| FaxNumber: | 2524430572 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 05/06/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 34389 | NC | N | Allopathic & Osteopathic Physicians | Anesthesiology | 208VP0014X | 34389 | NC | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7953696 | 05 | NC | MEDICAID |