Provider Demographics
NPI:1912972456
Name:GLUCK, BRIAN (DO)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:GLUCK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 E SHERMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-1813
Mailing Address - Country:US
Mailing Address - Phone:231-737-8446
Mailing Address - Fax:231-737-0510
Practice Address - Street 1:1325 E SHERMAN BLVD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1813
Practice Address - Country:US
Practice Address - Phone:231-737-8446
Practice Address - Fax:231-737-0510
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-20
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011457208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0256110464OtherBLUE CROSS BLUE SHIELD
MI114687630Medicaid
MI0256110464OtherBLUE CROSS BLUE SHIELD
MI114687630Medicaid