Provider Demographics
NPI:1689675878
Name:TAYLOR, GLENN (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26850 PROVIDENCE PKWY
Mailing Address - Street 2:SUITE 370
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48374-1213
Mailing Address - Country:US
Mailing Address - Phone:248-465-4160
Mailing Address - Fax:248-465-5425
Practice Address - Street 1:26850 PROVIDENCE PKWY
Practice Address - Street 2:SUITE 370
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374-1213
Practice Address - Country:US
Practice Address - Phone:248-465-4160
Practice Address - Fax:248-465-4525
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301407458207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI305718810Medicaid
BT1304841OtherCONTROLLED SUBSTANCE
MI4301407458OtherCONTROLLED SUBSTANCE
MI0F36020013Medicare ID - Type Unspecified
MI305718810Medicaid