Provider Demographics
NPI:1841290970
Name:GLENN, BRIAN L (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:L
Last Name:GLENN
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 1:401 S. BALLENGER HWY
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3638
Mailing Address - Country:US
Mailing Address - Phone:810-342-1000
Mailing Address - Fax:810-342-1591
Practice Address - Street 1:1254 N. MAIN ST
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446
Practice Address - Country:US
Practice Address - Phone:810-664-4531
Practice Address - Fax:810-667-7337
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0051841207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GL000425Medicare ID - Type Unspecified
G61885Medicare UPIN