Provider Demographics
NPI:1063433050
Name:HIDDEN, GLEN ALLEN (MD)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:ALLEN
Last Name:HIDDEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 E HOSPITAL ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:MANNING
Mailing Address - State:SC
Mailing Address - Zip Code:29102-3149
Mailing Address - Country:US
Mailing Address - Phone:803-435-5250
Mailing Address - Fax:803-435-5255
Practice Address - Street 1:50 E HOSPITAL ST
Practice Address - Street 2:SUITE 4
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-3149
Practice Address - Country:US
Practice Address - Phone:803-435-5250
Practice Address - Fax:803-435-5255
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2010-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043063207Q00000X
SC22420207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA872533996AMedicaid
GA872533996AMedicaid
G67528Medicare UPIN