Provider Demographics
NPI:1629138607
Name:HOORT, GLENN A (DPM)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:A
Last Name:HOORT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:854 S. WASHINGTON AVENUE
Mailing Address - Street 2:SUITE 430
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-7141
Mailing Address - Country:US
Mailing Address - Phone:616-392-6117
Mailing Address - Fax:616-392-1920
Practice Address - Street 1:854 S. WASHINGTON AVENUE
Practice Address - Street 2:SUITE 430
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-7141
Practice Address - Country:US
Practice Address - Phone:616-392-6117
Practice Address - Fax:616-392-1920
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901000884213E00000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI485705000OtherBLUE CROSS BLUE SHEILD
MI2115198Medicaid
MI480000546OtherADMINISTAR
MI4857005000OtherBLUECROSSBLUESHIELDMI
T34249Medicare UPIN
MIT34249Medicare UPIN
MI0564630001Medicare NSC
MI4857005000OtherBLUECROSSBLUESHIELDMI