1316129919 NPI number — LAURIE GLANZ

Table of content: (NPI 1316129919)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316129919 NPI number — LAURIE GLANZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAURIE GLANZ
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:
DISORDERS OF THE FOOT
Provider Other Organization Name Type Code:
3
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:
1316129919
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
35 CHURCH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT CLEMENS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48043-2331
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-463-1555
Provider Business Mailing Address Fax Number:
586-463-7550

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35 CHURCH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT CLEMENS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48043-2331
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-463-1555
Provider Business Practice Location Address Fax Number:
586-463-7550
Provider Enumeration Date:
12/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GLANZ
Authorized Official First Name:
LAURIE
Authorized Official Middle Name:
BETH
Authorized Official Title or Position:
LAURIE B GLANZ DPM
Authorized Official Telephone Number:
586-463-1555

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  LG001020 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 335E00000X , with the licence number: LG001020 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1397171 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 480002510 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: LG001020 . This is a "LICENSE NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4855050200 . This is a "BCBS PIN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: P79090 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: ADR5 . This is a "NEIC SITE ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 145899 . This is a "SELECTCARE PROVIDER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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