MEDICARE: GLENN EDWARD FUSSELL M.D.

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	207Q00000X	Family Medicine Physician	026777	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	6485960001	OTHER	GA	NSC PTAN

General Provider Information

NPI Number	:	1861509184
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLENN EDWARD FUSSELL M.D.

Provider Business Mailing Address
First Line	:	2827 WARM SPRINGS RD
Second Line	:	SUITE 3-B
City	:	COLUMBUS
State	:	GA
Zip	:	31904-5246
Country	:	US
Telephone Number	:	706-324-4177
Fax Number	:

Provider Business Practice Location Address
First Line	:	2827 WARM SPRINGS RD
Second Line	:	SUITE 3-B
City	:	COLUMBUS
State	:	GA
Zip	:	31904-5246
Country	:	US
Telephone Number	:	706-324-4177
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2006
Last Update Date	:	01/31/2014

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