Healthcare Provider Details

I. General information

NPI: 1346511029
Provider Name (Legal Business Name): GLAZER SPINE CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2012
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24725 W. 12 MILE RD SUITE 260
SOUTHFIELD MI
48034
US

IV. Provider business mailing address

24725 W. 12 MILE RD SUITE 260
SOUTHFIELD MI
48034
US

V. Phone/Fax

Practice location:
  • Phone: 248-353-2225
  • Fax: 248-353-2239
Mailing address:
  • Phone: 248-353-2225
  • Fax: 248-353-2239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2301007367
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. SHELBY ROSS GLAZER
Title or Position: OWNER
Credential: DC
Phone: 248-353-2225