Provider Demographics
NPI:1437343373
Name:GLENDA M GENSOLIN MD PLLC
Entity Type:Organization
Organization Name:GLENDA M GENSOLIN MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GENSOLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-683-0330
Mailing Address - Street 1:24 N SAINT JOSEPH AVE STE C2
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-2263
Mailing Address - Country:US
Mailing Address - Phone:269-683-0330
Mailing Address - Fax:269-684-0400
Practice Address - Street 1:24 N SAINT JOSEPH AVE STE C2
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-2263
Practice Address - Country:US
Practice Address - Phone:269-683-0330
Practice Address - Fax:269-684-0400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-04
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301090975261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
1033195748OtherNPI