1285632364 NPI number — GLENNAN MEDICAL GROUP PC

Table of content: (NPI 1285632364)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285632364 NPI number — GLENNAN MEDICAL GROUP PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GLENNAN MEDICAL GROUP PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285632364
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
72 S WASHINGTON ST
Provider Second Line Business Mailing Address:
SUITE 204
Provider Business Mailing Address City Name:
OXFORD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48371-6421
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-628-2233
Provider Business Mailing Address Fax Number:
248-628-2384

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
72 S WASHINGTON ST
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
OXFORD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48371-6421
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-628-2233
Provider Business Practice Location Address Fax Number:
248-628-2384
Provider Enumeration Date:
07/12/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WISSMAN
Authorized Official First Name:
SHERYL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
248-628-2233

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  4301051927 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 125218 . This is a "PREFERRED CHOICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 7023567 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: CF9338 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: I17832 . This is a "HAP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 110F302700 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4266551 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: E49479 . This is a "HAP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1011749 . This is a "HEALTH ADVANTAGE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4603282 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4406452 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com