Provider Demographics
NPI:1972611770
Name:SISK, GLENN ARDEN (DC)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:ARDEN
Last Name:SISK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10800 BELLEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48111-5304
Mailing Address - Country:US
Mailing Address - Phone:734-697-3210
Mailing Address - Fax:734-697-5603
Practice Address - Street 1:10800 BELLEVILLE RD
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48111-5304
Practice Address - Country:US
Practice Address - Phone:734-697-3210
Practice Address - Fax:734-697-5603
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIGS006907111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N52720Medicare ID - Type Unspecified
MIU60138Medicare UPIN