Provider Demographics
NPI:1033195748
Name:GENSOLIN, GLENDA M (MD)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:M
Last Name:GENSOLIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 N SAINT JOSEPH AVE STE C2
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-2263
Mailing Address - Country:US
Mailing Address - Phone:269-683-0330
Mailing Address - Fax:269-684-0400
Practice Address - Street 1:24 N SAINT JOSEPH AVE STE C2
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-2263
Practice Address - Country:US
Practice Address - Phone:269-683-0330
Practice Address - Fax:269-684-0400
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-15
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35068802G207Q00000X
MI4301090975207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1437343373OtherGROUP NPI
MIOP49570Medicare PIN
G28029Medicare UPIN