Provider Demographics
NPI:1669672705
Name:GLORY VISITING PHYSICIAN PC.
Entity Type:Organization
Organization Name:GLORY VISITING PHYSICIAN PC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NEUROLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARISE
Authorized Official - Middle Name:LANETTE
Authorized Official - Last Name:VALENTINE
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:248-569-5476
Mailing Address - Street 1:30063 RAMBLING RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-1038
Mailing Address - Country:US
Mailing Address - Phone:248-569-5476
Mailing Address - Fax:248-424-8987
Practice Address - Street 1:4245 S BEECH DALY ST
Practice Address - Street 2:
Practice Address - City:DEARBORN HTS
Practice Address - State:MI
Practice Address - Zip Code:48125-1567
Practice Address - Country:US
Practice Address - Phone:248-569-5476
Practice Address - Fax:248-424-8987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301053752320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIA16112OtherUPIN