Healthcare Provider Details

I. General information

NPI: 1942695739
Provider Name (Legal Business Name): STUART GLASS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2015
Last Update Date: 09/02/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 N MAIN ST
KENANSVILLE NC
28349-8801
US

IV. Provider business mailing address

401 N MAIN ST
KENANSVILLE NC
28349-8801
US

V. Phone/Fax

Practice location:
  • Phone: 910-296-0941
  • Fax:
Mailing address:
  • Phone: 910-296-0941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number80140
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2021-02238
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: