Healthcare Provider Details

I. General information

NPI: 1437684453
Provider Name (Legal Business Name): SPECIALTY ORTHOPAEDICS AND SPORTS MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2017
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 CRISANTO AVENUE SUITE B
FORT MILL SC
29715
US

IV. Provider business mailing address

130 CRISANTO AVENUE SUITE B
FORT MILL SC
29715
US

V. Phone/Fax

Practice location:
  • Phone: 803-548-6464
  • Fax: 803-396-8440
Mailing address:
  • Phone: 803-548-6464
  • Fax: 803-396-8440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. GLEN T FELTHAM
Title or Position: OWNER, PHYSICIAN
Credential: M.D.
Phone: 570-452-0097