Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0203X | Pediatric Critical Care Doctor | 4301050097 | MI |
NPI | 1144200742 |
---|---|
Provider Name | Glen D Libby |
First Address | Kalamazoo, MI 49007-5341 |
Second Address | Kalamazoo, MI 49007-5341 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/01/2006 |
Last Update Date | 16/10/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1744625 | (05) | MI |
A79872 | (02) |