Provider Demographics
NPI:1952389132
Name:MURRY, GLENN (PAC)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:MURRY
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38935 ANN ARBOR RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-3354
Mailing Address - Country:US
Mailing Address - Phone:734-632-0175
Mailing Address - Fax:734-632-0182
Practice Address - Street 1:33155 ANNAPOLIS
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-2405
Practice Address - Country:US
Practice Address - Phone:734-467-4042
Practice Address - Fax:734-467-5500
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002456363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
11712561OtherCAQH
MIS43095Medicare UPIN
MIN86630006Medicare ID - Type Unspecified