Provider Demographics
NPI:1013953298
Name:DELONG, GLENN A (DO)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:A
Last Name:DELONG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8836
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49518
Mailing Address - Country:US
Mailing Address - Phone:866-898-7139
Mailing Address - Fax:616-975-9824
Practice Address - Street 1:1000 HARRINGTON BLVD
Practice Address - Street 2:
Practice Address - City:MT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043
Practice Address - Country:US
Practice Address - Phone:586-493-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010103414207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI112877321Medicaid
0155025145OtherBCBS
MI112877321Medicaid
930049651Medicare PIN
5502514Medicare PIN