Provider Demographics
NPI:1669439550
Name:HASTINGS, GLEN HOWARD (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:HOWARD
Last Name:HASTINGS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2990 NILES RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-8607
Mailing Address - Country:US
Mailing Address - Phone:269-983-3368
Mailing Address - Fax:269-983-2758
Practice Address - Street 1:2990 NILES RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-8607
Practice Address - Country:US
Practice Address - Phone:269-983-3368
Practice Address - Fax:269-983-2758
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301 406148208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4170368 10Medicaid
MI0M94080002Medicare PIN
MIE68365Medicare UPIN