Provider Demographics
NPI:1154475523
Name:GLYNN, THEODORE E (MD)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:E
Last Name:GLYNN
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 1:1215 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-1811
Mailing Address - Country:US
Mailing Address - Phone:517-364-3895
Mailing Address - Fax:
Practice Address - Street 1:5303 S CEDAR ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-3800
Practice Address - Country:US
Practice Address - Phone:517-887-4311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301071075174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI382168683OtherTAX ID
MI4548289Medicaid
MIH32886Medicare UPIN
MI382168683OtherTAX ID
MIC37626069Medicare PIN