Basic Information
Provider Information | |||||||||
NPI: | 1770744989 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BANEGURA | ||||||||
FirstName: | GLENN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1700 MEDICAL WAY | ||||||||
Address2: | HOSPITALIST OFFICE | ||||||||
City: | SNELLVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 300782195 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6179016120 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1000 MEDICAL CENTER DR | ||||||||
Address2: |   | ||||||||
City: | HARDEEVILLE | ||||||||
State: | SC | ||||||||
PostalCode: | 299273446 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8437848224 | ||||||||
FaxNumber: | 8437848006 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/19/2008 | ||||||||
LastUpdateDate: | 03/16/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/16/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 31509 | AL | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 208M00000X | 16816 | HI | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 208M00000X | 036147581 | IL | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 208M00000X | 60633025 | WA | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 208M00000X | 34002 | SC | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 208M00000X | 1796 | WI | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 208M00000X | 66752 | GA | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 340027 | 05 | SC |   | MEDICAID | SCB3975019 | 01 | SC | MEDICARE PIN | OTHER | SCB3979068 | 01 | SC | MEDICARE PIN | OTHER |