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General NPI Number Information
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NPI Number | 1053411165
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Entity Type | Individual
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Provider Name | SYDNEY GLEN SHORT MD
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Gender | Male
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Dates
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Enumeration Date | 09/25/2006
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Last Update Date | 07/01/2024
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Provider Practice Location Address
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Address Line | 568 RUIN CREEK RD STE 128
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City | HENDERSON
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State | NC
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Zip | 27536-5921
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Country | US
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Telephone | 252-436-1085
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Fax |
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Provider Business Mailing Address
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Address Line | 1030 SIENA DRIVE
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City | WAKE FOREST
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State | NC
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Zip | 27587
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Country | US
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Telephone | 910-734-4391
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 28344
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License Number State | ND
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Taxonomy #2
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number | 28344
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License Number State | NC
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