MEDICARE: GLENDA M GENSOLIN 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	207Q00000X	Family Medicine Physician	35068802G	OH
2	207Q00000X	Family Medicine Physician	4301090975	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1437343373	OTHER	MI	GROUP NPI

General Provider Information

NPI Number	:	1033195748
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLENDA M GENSOLIN MD

Provider Business Mailing Address
First Line	:	24 N SAINT JOSEPH AVE STE C2
Second Line	:
City	:	NILES
State	:	MI
Zip	:	49120-2263
Country	:	US
Telephone Number	:	269-683-0330
Fax Number	:	269-684-0400

Provider Business Practice Location Address
First Line	:	24 N SAINT JOSEPH AVE STE C2
Second Line	:
City	:	NILES
State	:	MI
Zip	:	49120-2263
Country	:	US
Telephone Number	:	269-683-0330
Fax Number	:	269-684-0400

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

Provider Enumeration Date	:	12/15/2005
Last Update Date	:	03/10/2014

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1437343373 — GLENDA M GENSOLIN MD PLLC
Practice Location Address:

24 N SAINT JOSEPH AVE STE C2
NILES, MI
49120-2263

Practice Phone: 269-683-0330
Practice Fax: 269-684-0400

Directions to “ GLENDA M GENSOLIN MD” Practice Location

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