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General NPI Number Information
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NPI Number | 1679947949
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Entity Type | Individual
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Provider Name | GLENN MICHELSON M.D.
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Gender | Male
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Dates
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Enumeration Date | 11/23/2015
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Last Update Date | 08/24/2016
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Provider Practice Location Address
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Address Line | 91 BOLIVAR DR
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City | BERKELEY
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State | CA
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Zip | 94710-2210
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Country | US
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Telephone | 510-647-4252
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Fax | 510-548-8014
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Provider Business Mailing Address
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Address Line | 91 BOLIVAR DR
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City | BERKELEY
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State | CA
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Zip | 94710-2210
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Country | US
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Telephone | 510-647-4252
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Fax | 510-548-8014
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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 | 207RH0003X
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Taxonomy Name | Hematology & Oncology Physician
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License Number | G85101
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License Number State | CA
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