Healthcare Provider Details

I. General information

NPI: 1912972449
Provider Name (Legal Business Name): GLENN D. LUBASH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2006
Last Update Date: 07/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 FAIRVIEW RD
MOORESVILLE NC
28117-9500
US

IV. Provider business mailing address

PO BOX 1350 SUITE 5
MOORESVILLE NC
28115-1350
US

V. Phone/Fax

Practice location:
  • Phone: 704-660-4000
  • Fax:
Mailing address:
  • Phone: 707-799-3380
  • Fax: 704-799-6315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: