MEDICARE: COURTNEY GLENN DPM LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP1100X	Podiatric Clinic/Center	POD001277	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1831454750	OTHER		PERSONAL NPI NUMBER

General Provider Information

NPI Number	:	1306221106
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COURTNEY GLENN DPM LLC

Provider Business Mailing Address
First Line	:	1515 RIVER PL STE 370
Second Line	:
City	:	BRASELTON
State	:	GA
Zip	:	30517-5605
Country	:	US
Telephone Number	:	770-648-5040
Fax Number	:	706-780-5366

Provider Business Practice Location Address
First Line	:	1515 RIVER PL STE 370
Second Line	:
City	:	BRASELTON
State	:	GA
Zip	:	30517-5605
Country	:	US
Telephone Number	:	770-648-5040
Fax Number	:	706-780-5366

Authorized Official
Title or Position	:	OWNER
Name	:	COURTNEY GLENN
Credential	:	DPM
Telephone Number	:	814-758-8425

Provider Enumeration Date	:	07/22/2015
Last Update Date	:	12/29/2025

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