Healthcare Provider Details

I. General information

NPI: 1245228709
Provider Name (Legal Business Name): MICHAEL CHARLES MCGLYNN CFNP
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W WASHINGTON AVE STE 150
JACKSON MI
49201-2180
US

IV. Provider business mailing address

300 W WASHINGTON AVE STE 150
JACKSON MI
49201-2180
US

V. Phone/Fax

Practice location:
  • Phone: 517-783-4664
  • Fax: 517-783-4698
Mailing address:
  • Phone: 517-783-4664
  • Fax: 517-783-4698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704202462
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: