Provider Demographics
NPI:1154426518
Name:GLASS, LIONEL (MD)
Entity type:Individual
Prefix:
First Name:LIONEL
Middle Name:
Last Name:GLASS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1976 S LA CIENEGA BLVD
Mailing Address - Street 2:# 255
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90034-1627
Mailing Address - Country:US
Mailing Address - Phone:866-485-1399
Mailing Address - Fax:206-333-0668
Practice Address - Street 1:43494 WOODWARD AVENUE
Practice Address - Street 2:SUITE 103
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-0567
Practice Address - Country:US
Practice Address - Phone:866-485-1399
Practice Address - Fax:206-333-0668
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2010-06-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI43010310942084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI27-2558278OtherTAX ID
MI103504593Medicaid
MI130635749OtherBCBS
MI0M59060Medicare ID - Type Unspecified
MI103504593Medicaid