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General NPI Number Information
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NPI Number | 1083704175
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Entity Type | Individual
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Provider Name | ROBERT GLEN QUATTLEBAUM M.D.
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Gender | Male
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Dates
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Enumeration Date | 10/13/2006
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Last Update Date | 02/16/2023
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Provider Practice Location Address
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Address Line | 885 TIGER BLVD
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City | CLEMSON
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State | SC
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Zip | 29631-1480
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Country | US
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Telephone | 864-512-7257
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Fax | 864-654-3261
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Provider Business Mailing Address
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Address Line | PO BOX 100174
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City | COLUMBIA
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State | SC
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Zip | 29202-3174
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Country | US
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Telephone | 864-512-7257
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Fax | 864-654-3261
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 27937
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License Number State | SC
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