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General NPI Number Information
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NPI Number | 1053760728
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Entity Type | Individual
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Provider Name | COURTNEY ELIZABETH GLOS M.D.
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Gender | Female
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Dates
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Enumeration Date | 06/03/2016
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Last Update Date | 03/12/2024
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Provider Practice Location Address
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Address Line | 200 ALFRED ST
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City | MICHIGAN CITY
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State | IN
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Zip | 46360
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Country | US
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Telephone | 219-872-6200
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Fax | 219-879-2915
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Provider Business Mailing Address
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Address Line | 710 FRANKLIN ST STE 200
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City | MICHIGAN CITY
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State | IN
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Zip | 46360-3564
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Country | US
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Telephone | 219-872-6200
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Fax | 219-879-2915
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 01082430A
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License Number State | IN
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