Healthcare Provider Details

I. General information

NPI: 1982623716
Provider Name (Legal Business Name): LARRY GLASS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 04/06/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7800 PROVIDENCE RD STE 203
CHARLOTTE NC
28226-2952
US

IV. Provider business mailing address

PO BOX 19305
CHARLOTTE NC
28219-9305
US

V. Phone/Fax

Practice location:
  • Phone: 704-512-2610
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0032503
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: