MEDICARE: GLENN MURRY PAC

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	363A00000X	Physician Assistant	5601002456	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11712561	OTHER		CAQH

General Provider Information

NPI Number	:	1952389132
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLENN MURRY PAC

Provider Business Mailing Address
First Line	:	38935 ANN ARBOR RD
Second Line	:
City	:	LIVONIA
State	:	MI
Zip	:	48150-3354
Country	:	US
Telephone Number	:	734-632-0175
Fax Number	:	734-632-0182

Provider Business Practice Location Address
First Line	:	33155 ANNAPOLIS
Second Line	:	EMERGENCY DEPARTMENT
City	:	WAYNE
State	:	MI
Zip	:	48184-2405
Country	:	US
Telephone Number	:	734-467-4042
Fax Number	:	734-467-5500

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

Provider Enumeration Date	:	01/06/2006
Last Update Date	:	04/03/2013

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Directions to “ GLENN MURRY PAC” Practice Location

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