Healthcare Provider Details

I. General information

NPI: 1851412878
Provider Name (Legal Business Name): MICHAEL L GLASS MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 11/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3815 S BOULEVARD ST
EDMOND OK
73013-5479
US

IV. Provider business mailing address

3815 S BOULEVARD ST
EDMOND OK
73013-5479
US

V. Phone/Fax

Practice location:
  • Phone: 405-341-9996
  • Fax: 405-330-3566
Mailing address:
  • Phone: 405-341-9996
  • Fax: 405-330-3566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202C00000X
TaxonomyIndependent Medical Examiner Physician
License Number11886
License Number StateOK

VIII. Authorized Official

Name: DR. MICHAEL L GLASS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 405-341-9996