Provider Demographics
NPI:1871549055
Name:BROTHERS, GLENN T (DO)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:T
Last Name:BROTHERS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 743294
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3294
Mailing Address - Country:US
Mailing Address - Phone:864-834-4151
Mailing Address - Fax:864-834-6145
Practice Address - Street 1:406 N POINSETT HWY
Practice Address - Street 2:GATEWAY FAMILY MEDICINE
Practice Address - City:TRAVELERS REST
Practice Address - State:SC
Practice Address - Zip Code:29690-1667
Practice Address - Country:US
Practice Address - Phone:864-834-4151
Practice Address - Fax:864-834-6145
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC39795207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00353360OtherRAILROAD MEDICARE
SC397957Medicaid
SCSC88768157Medicare PIN
MOP00353360OtherRAILROAD MEDICARE
H82163Medicare UPIN