Provider Demographics
NPI:1083673628
Name:GLYNN, MICHAEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:GLYNN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 E RIVER RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718
Mailing Address - Country:US
Mailing Address - Phone:520-795-7923
Mailing Address - Fax:520-320-2155
Practice Address - Street 1:2450 E RIVER RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718
Practice Address - Country:US
Practice Address - Phone:520-795-7923
Practice Address - Fax:520-320-2155
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ197282084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ162834Medicaid
E11110Medicare UPIN
AZ162834Medicaid