MEDICARE: ANDREW THOMAS GLAZA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	LL94941	SC

General Provider Information

NPI Number	:	1053114447
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREW THOMAS GLAZA MD

Provider Business Mailing Address
First Line	:	169 ASHLEY AVENUE
Second Line	:	ROOM 202 MAIN HOSPITAL, MSC333
City	:	CHARLESTON
State	:	SC
Zip	:	29425
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	96 JONATHAN LUCAS ST # 420
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29425-6712
Country	:	US
Telephone Number	:	843-792-4638
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/31/2025
Last Update Date	:	06/28/2025

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