Provider Demographics
NPI:1669695870
Name:MOORE, GLENN (MD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5080 SPECTRUM DRIVE
Mailing Address - Street 2:SUITE 1200 WEST TOWER
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-4648
Mailing Address - Country:US
Mailing Address - Phone:800-232-3550
Mailing Address - Fax:
Practice Address - Street 1:40732 VAN DYKE AVE.
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-3741
Practice Address - Country:US
Practice Address - Phone:615-778-4066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010410812083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI1504001Medicare UPIN
MIP46120002Medicare UPIN
MIMI1503001Medicare UPIN
MIMI1504Medicare PIN
MIMI1503Medicare PIN
MIOP46120Medicare PIN