MEDICARE: DR. GLEN THOMAS FELTHAM 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	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician	39231	SC
2	207X00000X	Orthopaedic Surgery Physician	39231	SC

General Provider Information

NPI Number	:	1194716381
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GLEN THOMAS FELTHAM MD

Provider Business Mailing Address
First Line	:	130 CRISANTO AVENUE
Second Line	:	SUITE B
City	:	FORT MILL
State	:	SC
Zip	:	29715
Country	:	US
Telephone Number	:	803-548-6464
Fax Number	:	803-396-8440

Provider Business Practice Location Address
First Line	:	130 CRISANTO AVENUE
Second Line	:	SUITE B
City	:	FORT MILL
State	:	SC
Zip	:	29715
Country	:	US
Telephone Number	:	803-548-6464
Fax Number	:	803-396-8440

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

Provider Enumeration Date	:	11/04/2005
Last Update Date	:	01/31/2024

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