Provider Demographics
NPI:1427009646
Name:EKBLAD, GLENN (DO)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:
Last Name:EKBLAD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1535 GULL RD
Mailing Address - Street 2:MSB 015
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-1650
Mailing Address - Country:US
Mailing Address - Phone:269-226-6933
Mailing Address - Fax:269-226-6949
Practice Address - Street 1:1535 GULL RD
Practice Address - Street 2:MSB 015
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1650
Practice Address - Country:US
Practice Address - Phone:269-226-6933
Practice Address - Fax:269-226-6949
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007963207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2703663Medicaid
MI700G560080OtherBCBS GROUP-THREE RIVERS HEALTH
MIEG007963OtherBLUE CROSS BLUE SHIELD
MI2673680-11Medicaid
MI112703663Medicaid
MI114694447Medicaid
MI112703663Medicaid
MI230015Medicare Oscar/Certification
MI2703663Medicaid
MI2673680-11Medicaid
MIEG007963OtherBLUE CROSS BLUE SHIELD
MI0C96038023Medicare PIN