Provider Demographics
NPI:1285632364
Name:GLENNAN MEDICAL GROUP PC
Entity Type:Organization
Organization Name:GLENNAN MEDICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:WISSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-628-2233
Mailing Address - Street 1:72 S WASHINGTON ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:OXFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48371-6421
Mailing Address - Country:US
Mailing Address - Phone:248-628-2233
Mailing Address - Fax:248-628-2384
Practice Address - Street 1:72 S WASHINGTON ST
Practice Address - Street 2:SUITE 204
Practice Address - City:OXFORD
Practice Address - State:MI
Practice Address - Zip Code:48371-6421
Practice Address - Country:US
Practice Address - Phone:248-628-2233
Practice Address - Fax:248-628-2384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301051927207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI125218OtherPREFERRED CHOICES
MI7023567OtherAETNA
MICF9338OtherRAILROAD MEDICARE
MII17832OtherHAP
MI110F302700OtherBCBS
MI4266551OtherAETNA
MIE49479OtherHAP
MI1011749OtherHEALTH ADVANTAGE
MI4603282Medicaid
MI4406452Medicaid
MI4406452Medicaid