Healthcare Provider Details

I. General information

NPI: 1093663023
Provider Name (Legal Business Name): GLEGEN MEDICAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2026
Last Update Date: 03/17/2026
Certification Date: 03/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5165 NORTHLAND DR NE
GRAND RAPIDS MI
49525-1015
US

IV. Provider business mailing address

5165 NORTHLAND DR NE
GRAND RAPIDS MI
49525-1015
US

V. Phone/Fax

Practice location:
  • Phone: 877-340-1697
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. GLEB GENDEL
Title or Position: SOLE MBR
Credential: DO
Phone: 877-340-1697