Basic Information
| Provider Information | |||||||||
| NPI: | 1871548479 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WERNER | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1264 RIBAUT ROAD | ||||||||
| Address2: | BLDG 200 | ||||||||
| City: | BEAUFORT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435245455 | ||||||||
| FaxNumber: | 8435245655 | ||||||||
| Practice Location | |||||||||
| Address1: | 1264 RIBAUT ROAD | ||||||||
| Address2: | BLDG 200 | ||||||||
| City: | BEAUFORT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435245455 | ||||||||
| FaxNumber: | 8435245655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 15977 | SC | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | GP3884 | 05 | SC | MEDICAID |