MEDICARE: DR. GLENN MICHELSON M.D.

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	207RH0003X	Hematology & Oncology Physician	G85101	CA

General Provider Information

NPI Number	:	1679947949
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GLENN MICHELSON M.D.

Provider Business Mailing Address
First Line	:	91 BOLIVAR DR
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94710-2210
Country	:	US
Telephone Number	:	510-647-4252
Fax Number	:	510-548-8014

Provider Business Practice Location Address
First Line	:	91 BOLIVAR DR
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94710-2210
Country	:	US
Telephone Number	:	510-647-4252
Fax Number	:	510-548-8014

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/23/2015
Last Update Date	:	08/24/2016

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