Basic Information
| Provider Information | |||||||||
| NPI: | 1396760625 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GLENN | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | IV | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1245 | ||||||||
| Address2: | |||||||||
| City: | ORANGEBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291161245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033954497 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5073 CAROLINA HWY | ||||||||
| Address2: | |||||||||
| City: | DENMARK | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290421679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032455144 | ||||||||
| FaxNumber: | 8032456277 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 07/25/2016 | ||||||||
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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 | 207Q00000X | 19072 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 190723 | 05 | SC | MEDICAID |