Provider Demographics
NPI:1851412878
Name:MICHAEL L GLASS MD INC
Entity Type:Organization
Organization Name:MICHAEL L GLASS MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:GLASS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-341-9996
Mailing Address - Street 1:3815 S BOULEVARD ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-5479
Mailing Address - Country:US
Mailing Address - Phone:405-341-9996
Mailing Address - Fax:405-330-3566
Practice Address - Street 1:3815 S BOULEVARD ST
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-5479
Practice Address - Country:US
Practice Address - Phone:405-341-9996
Practice Address - Fax:405-330-3566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11886202C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes202C00000XAllopathic & Osteopathic PhysiciansIndependent Medical ExaminerGroup - Single Specialty