Basic Information
| Provider Information | |||||||||
| NPI: | 1740328053 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHEATON | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | TODD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 531 ROSELANE ST NW STE 830 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300606979 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707940477 | ||||||||
| FaxNumber: | 7707943108 | ||||||||
| Practice Location | |||||||||
| Address1: | 677 CHURCH ST NE | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707940477 | ||||||||
| FaxNumber: | 7707943108 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2007 | ||||||||
| LastUpdateDate: | 08/27/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP3000X | 044142 | GA | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology | 208VP0000X | 044142 | GA | N | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 208VP0014X | 044142 | GA | N | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 207L00000X | 044142 | GA | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 044142 | GA | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000755664A | 05 | GA | MEDICAID |