Provider Demographics
NPI:1215629993
Name:ANDERSON, GLENN ROBERT (BS)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:ROBERT
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:HANCOCK
Mailing Address - State:MI
Mailing Address - Zip Code:49930-1914
Mailing Address - Country:US
Mailing Address - Phone:906-281-0273
Mailing Address - Fax:
Practice Address - Street 1:9811 W CHARLESTON BLVD STE 2-2641
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-7528
Practice Address - Country:US
Practice Address - Phone:855-864-4322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic