=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972827244
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STEFAN GLOWACKI M.D.,P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2010
-----------------------------------------------------
Last Update Date | 08/07/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 42370 VAN DYKE AVE SUITE 107
-----------------------------------------------------
City | STERLING HEIGHTS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48314-3487
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-991-0051
-----------------------------------------------------
Fax | 586-991-0064
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 42370 VAN DYKE AVE SUITE 107
-----------------------------------------------------
City | STERLING HEIGHTS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48314-3487
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-991-0051
-----------------------------------------------------
Fax | 586-991-0064
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. STEFAN GLOWACKI
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 586-991-0051
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | SG040818
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------