Provider Demographics
NPI:1083716377
Name:GLOWACKI, MARTIN (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:GLOWACKI
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 1:6535 ROCHESTER RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-1362
Mailing Address - Country:US
Mailing Address - Phone:248-813-0060
Mailing Address - Fax:248-813-0066
Practice Address - Street 1:6535 ROCHESTER RD
Practice Address - Street 2:SUITE 102
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-1362
Practice Address - Country:US
Practice Address - Phone:248-813-0060
Practice Address - Fax:248-813-0066
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301080069208VP0014X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MG080069OtherCHAMPUS-CHAMPUS
MG080069OtherCOMMERCIAL-COMMERCIAL NUMBER
MG080069OtherCOMMERCIAL-COMMERCIAL NUMBER