Provider Demographics
NPI:1992708309
Name:CREEL, JOHN GLENN (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:GLENN
Last Name:CREEL
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 1:447 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:WALTERBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29488-2766
Mailing Address - Country:US
Mailing Address - Phone:843-549-6331
Mailing Address - Fax:843-549-6332
Practice Address - Street 1:447 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-2766
Practice Address - Country:US
Practice Address - Phone:843-549-6331
Practice Address - Fax:843-549-6332
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21776207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC217768Medicaid
SC217768Medicaid
SCH57208Medicare UPIN