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General NPI Number Information
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NPI Number | 1972761880
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Entity Type | Individual
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Provider Name | GLENN ROGER GROUSTRA MD
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Gender | Male
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Dates
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Enumeration Date | 05/28/2008
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Last Update Date | 05/28/2008
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Provider Practice Location Address
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Address Line | 555 E WILLIAM ST SUITE 22I
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City | ANN ARBOR
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State | MI
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Zip | 48104
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Country | US
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Telephone | 734-663-5242
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Fax | 734-663-5242
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Provider Business Mailing Address
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Address Line | 555 E WILLIAM ST SUITE 22I
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City | ANN ARBOR
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State | MI
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Zip | 48104
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Country | US
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Telephone | 734-663-5242
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Fax | 734-663-5242
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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 | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 4301023788
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License Number State | MI
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