Basic Information
| Provider Information | |||||||||
| NPI: | 1407904493 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLEN | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | COLEMAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 721 OKATIE HWY # 170 | ||||||||
| Address2: | |||||||||
| City: | OKATIE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299093963 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8439877400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 716 E 71ST ST | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314054907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123551533 | ||||||||
| FaxNumber: | 9123555984 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2007 | ||||||||
| LastUpdateDate: | 03/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 21984 | GA | N | Other Service Providers | Specialist | 207RG0100X | 7816 | SC | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207R00000X | 7816 | SC | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00234429A | 05 | GA | MEDICAID | G07186 | 05 | SC | MEDICAID |