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General NPI Number Information
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NPI Number | 1538116959
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Entity Type | Individual
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Provider Name | KENDAL ELIZABETH GLUCK MD
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Gender | Female
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Dates
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Enumeration Date | 05/30/2006
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Last Update Date | 03/22/2011
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Provider Practice Location Address
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Address Line | 701 W RANDALL ST
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City | COOPERSVILLE
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State | MI
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Zip | 49404-1369
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Country | US
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Telephone | 616-974-4860
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Fax |
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Provider Business Mailing Address
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Address Line | 100 MICHIGAN ST NE MC845
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City | GRAND RAPIDS
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State | MI
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Zip | 49503-2560
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Country | US
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Telephone |
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Fax |
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 4301078284
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License Number State | MI
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