Provider Demographics
NPI:1043579055
Name:PAMBID, GLOWILL
Entity Type:Individual
Prefix:MR
First Name:GLOWILL
Middle Name:
Last Name:PAMBID
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4067 LOUELLA DR
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-4124
Mailing Address - Country:US
Mailing Address - Phone:248-238-6279
Mailing Address - Fax:
Practice Address - Street 1:1411 3RD ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-5480
Practice Address - Country:US
Practice Address - Phone:800-451-0481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-10
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016109225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1043579055Medicaid