Healthcare Provider Details

I. General information

NPI: 1184882524
Provider Name (Legal Business Name): MICHELLE A GLASGOW M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2008
Last Update Date: 03/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 NORTHSIDE CHEROKEE BLVD STE 400
CANTON GA
30115-8023
US

IV. Provider business mailing address

980 JOHNSON FERRY RD STE 900
ATLANTA GA
30342-4768
US

V. Phone/Fax

Practice location:
  • Phone: 770-721-9400
  • Fax: 770-721-9401
Mailing address:
  • Phone: 404-459-1900
  • Fax: 678-354-7992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number67423
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number067423
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: