Healthcare Provider Details

I. General information

NPI: 1639167471
Provider Name (Legal Business Name): GLEN ENZENBERGER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 GERMAN ST
TAWAS CITY MI
48763-9349
US

IV. Provider business mailing address

700 GERMAN ST
TAWAS CITY MI
48763-9349
US

V. Phone/Fax

Practice location:
  • Phone: 989-362-4170
  • Fax: 989-362-0034
Mailing address:
  • Phone: 989-362-4170
  • Fax: 989-362-0034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101010568
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: