Provider Demographics
NPI:1215098090
Name:HITTEL, GLENN PAUL (MD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:PAUL
Last Name:HITTEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:221 TECHNOLOGY PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1369
Mailing Address - Country:US
Mailing Address - Phone:762-235-1000
Mailing Address - Fax:
Practice Address - Street 1:150 GENTILLY BLVD
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-8522
Practice Address - Country:US
Practice Address - Phone:770-382-2580
Practice Address - Fax:770-386-7910
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034159207QG0300X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000457564BMedicaid
GA000457564BMedicaid
GA08BDNBFMedicare PIN