Provider Demographics
NPI:1316965726
Name:PORTWOOD, GLEN LOY (MD)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:LOY
Last Name:PORTWOOD
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 1:11301 CARMEL COMMONS BLVD
Mailing Address - Street 2:STE 302
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-5305
Mailing Address - Country:US
Mailing Address - Phone:704-372-7974
Mailing Address - Fax:704-372-5166
Practice Address - Street 1:101 E WT HARRIS BLVD STE 3111
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-7002
Practice Address - Country:US
Practice Address - Phone:704-547-8818
Practice Address - Fax:704-547-9865
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9300570207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5901259Medicaid
NCF20611Medicare UPIN
NC2195041AMedicare ID - Type Unspecified