MEDICARE: GLENDA M GENSOLIN MD PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center	4301090975	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1033195748	OTHER		NPI

General Provider Information

NPI Number	:	1437343373
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLENDA M GENSOLIN MD PLLC

Provider Business Mailing Address
First Line	:	24 N SAINT JOSEPH AVE STE C2
Second Line	:
City	:	NILES
State	:	MI
Zip	:	49120-2263
Country	:	US
Telephone Number	:	269-683-0330
Fax Number	:	269-684-0400

Provider Business Practice Location Address
First Line	:	24 N SAINT JOSEPH AVE STE C2
Second Line	:
City	:	NILES
State	:	MI
Zip	:	49120-2263
Country	:	US
Telephone Number	:	269-683-0330
Fax Number	:	269-684-0400

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GLENDA M GENSOLIN
Credential	:	MD
Telephone Number	:	269-683-0330

Provider Enumeration Date	:	09/04/2007
Last Update Date	:	03/10/2014

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