Basic Information
| Provider Information | |||||||||
| NPI: | 1790991339 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GLUZBERG | ||||||||
| FirstName: | TATYANA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2747 | ||||||||
| Address2: | |||||||||
| City: | MURRELLS INLET | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295762662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433571299 | ||||||||
| FaxNumber: | 8439572264 | ||||||||
| Practice Location | |||||||||
| Address1: | 4959 HIGHWAY 17 BYPASS S. | ||||||||
| Address2: | |||||||||
| City: | MURRELLS INLET | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295765041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433571299 | ||||||||
| FaxNumber: | 8433572264 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2007 | ||||||||
| LastUpdateDate: | 02/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 32060 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 320600 | 05 | SC | MEDICAID |