Healthcare Provider Details

I. General information

NPI: 1821398660
Provider Name (Legal Business Name): MARK CHRISTOPHER GLOTKOWSKI PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2010
Last Update Date: 07/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E MEDICAL CENTER DR 2ND FLOOR TAUBMAN CTR RECP G
ANN ARBOR MI
48109-5338
US

IV. Provider business mailing address

4967 CROOKS RD STE 130
TROY MI
48098-5801
US

V. Phone/Fax

Practice location:
  • Phone: 734-936-7010
  • Fax:
Mailing address:
  • Phone: 248-952-1601
  • Fax: 248-952-1614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601005904
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: