Healthcare Provider Details

I. General information

NPI: 1124173026
Provider Name (Legal Business Name): SIMON MALCOLM GLYNN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 12/30/2024
Certification Date: 12/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E MEDICAL CENTER DR
ANN ARBOR MI
48109-5000
US

IV. Provider business mailing address

3621 S STATE ST
ANN ARBOR MI
48108-1633
US

V. Phone/Fax

Practice location:
  • Phone: 734-936-4000
  • Fax:
Mailing address:
  • Phone: 734-647-5299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number4301093239
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD427264
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number4301093239
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License Number4301093239
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: