Provider Demographics
NPI:1063614204
Name:GLENN S SHEAR MDPC
Entity type:Organization
Organization Name:GLENN S SHEAR MDPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:S
Authorized Official - Last Name:SHEAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-991-1624
Mailing Address - Street 1:33 UPPER RIVERDALE RD SW
Mailing Address - Street 2:SUITE 114
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2626
Mailing Address - Country:US
Mailing Address - Phone:770-991-1624
Mailing Address - Fax:770-991-9206
Practice Address - Street 1:33 UPPER RIVERDALE RD SW
Practice Address - Street 2:SUITE 114
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2626
Practice Address - Country:US
Practice Address - Phone:770-991-1624
Practice Address - Fax:770-991-9206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP370Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
GA0764030001Medicare NSC