Provider Demographics
NPI:1376563130
Name:BETRUS, GLENN GEORGE (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:GEORGE
Last Name:BETRUS
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 1:1037 WATER ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-4408
Mailing Address - Country:US
Mailing Address - Phone:810-984-4194
Mailing Address - Fax:810-984-4674
Practice Address - Street 1:1037 WATER ST
Practice Address - Street 2:SUITE 1
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-4408
Practice Address - Country:US
Practice Address - Phone:810-984-4194
Practice Address - Fax:810-984-4674
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301052886208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI540G41006OtherBLUE CROSS
MI102916887Medicaid
MIF48414Medicare UPIN
MI102916887Medicaid
MIN87370003Medicare ID - Type Unspecified