Basic Information
| Provider Information | |||||||||
| NPI: | 1912060633 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ACKERMAN | ||||||||
| FirstName: | GLEN | ||||||||
| MiddleName: | NEIL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 804 SERVICE ROAD | ||||||||
| Address2: | ROOM A217 | ||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488247040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173538122 | ||||||||
| FaxNumber: | 5174323713 | ||||||||
| Practice Location | |||||||||
| Address1: | 804 SERVICE RD | ||||||||
| Address2: | ROOM A217 | ||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488241376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173538122 | ||||||||
| FaxNumber: | 5174323713 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2006 | ||||||||
| LastUpdateDate: | 10/22/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 4301046992 | MI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 3216856 | 05 | MI | MEDICAID | 1912060633 | 05 | MI | MEDICAID |