Provider Demographics
NPI:1144200742
Name:LIBBY, GLEN D (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:D
Last Name:LIBBY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:601 JOHN ST
Mailing Address - Street 2:SUITE 352
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-341-8986
Mailing Address - Fax:269-341-6236
Practice Address - Street 1:601 JOHN ST
Practice Address - Street 2:STE 352
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5341
Practice Address - Country:US
Practice Address - Phone:269-341-8986
Practice Address - Fax:269-341-6236
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2014-10-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI43010500972080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1744625Medicaid
MI1744625Medicaid
MI0C97618073Medicare PIN