MEDICARE: GLORY VISITING PHYSICIAN PC.

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	320700000X	Physical Disabilities Residential Treatment Facility	4301053752	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	A16112	OTHER	MI	UPIN

General Provider Information

NPI Number	:	1669672705
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLORY VISITING PHYSICIAN PC.

Provider Business Mailing Address
First Line	:	30063 RAMBLING RD
Second Line	:
City	:	SOUTHFIELD
State	:	MI
Zip	:	48076-1038
Country	:	US
Telephone Number	:	248-569-5476
Fax Number	:	248-424-8987

Provider Business Practice Location Address
First Line	:	4245 S BEECH DALY ST
Second Line	:
City	:	DEARBORN HTS
State	:	MI
Zip	:	48125-1567
Country	:	US
Telephone Number	:	248-569-5476
Fax Number	:	248-424-8987

Authorized Official
Title or Position	:	NEUROLOGIST
Name	:	DR. CHARISE LANETTE VALENTINE
Credential	:	M. D.
Telephone Number	:	248-569-5476

Provider Enumeration Date	:	07/18/2007
Last Update Date	:	06/08/2015

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