Provider Demographics
NPI:1679543292
Name:GRADIS, GLENN A (DO)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:A
Last Name:GRADIS
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:3950 S ROCHESTER RD
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-5160
Mailing Address - Country:US
Mailing Address - Phone:248-844-6000
Mailing Address - Fax:248-844-6159
Practice Address - Street 1:3950 S ROCHESTER RD
Practice Address - Street 2:SUITE 1200
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-5160
Practice Address - Country:US
Practice Address - Phone:248-844-6000
Practice Address - Fax:248-844-6159
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2013-12-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5101006988207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700H273300OtherBLUE SHIELD GROUP
MI1679543292Medicaid
MI1679543292Medicaid
MIMI4989147Medicare PIN