Provider Demographics
NPI:1194716381
Name:FELTHAM, GLEN THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:THOMAS
Last Name:FELTHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 CRISANTO AVENUE
Mailing Address - Street 2:SUITE B
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715
Mailing Address - Country:US
Mailing Address - Phone:803-548-6464
Mailing Address - Fax:803-396-8440
Practice Address - Street 1:130 CRISANTO AVENUE
Practice Address - Street 2:SUITE B
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715
Practice Address - Country:US
Practice Address - Phone:803-548-6464
Practice Address - Fax:803-396-8440
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC39231207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAH34782Medicare UPIN
VA008235T25Medicare ID - Type Unspecified
VA010191432Medicaid
VAP00247942OtherRAILROAD MEDICARE