Provider Demographics
NPI:1871678144
Name:GROOM, GLENN CURTIS (PA)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:CURTIS
Last Name:GROOM
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:800 M 139
Mailing Address - Street 2:
Mailing Address - City:BENTON HARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49022-3881
Mailing Address - Country:US
Mailing Address - Phone:855-869-6900
Mailing Address - Fax:269-927-5493
Practice Address - Street 1:800 M 139
Practice Address - Street 2:
Practice Address - City:BENTON HARBOR
Practice Address - State:MI
Practice Address - Zip Code:49022-3881
Practice Address - Country:US
Practice Address - Phone:855-869-6900
Practice Address - Fax:269-927-5493
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004940363A00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q73277Medicare UPIN
MIMI1609059Medicare PIN