Healthcare Provider Details

I. General information

NPI: 1952389132
Provider Name (Legal Business Name): GLENN MURRY PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2006
Last Update Date: 04/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33155 ANNAPOLIS EMERGENCY DEPARTMENT
WAYNE MI
48184-2405
US

IV. Provider business mailing address

38935 ANN ARBOR RD
LIVONIA MI
48150-3354
US

V. Phone/Fax

Practice location:
  • Phone: 734-467-4042
  • Fax: 734-467-5500
Mailing address:
  • Phone: 734-632-0175
  • Fax: 734-632-0182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601002456
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: