Basic Information
| Provider Information | |||||||||
| NPI: | 1932254745 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GLISSON | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 245 CHERRY ST SE STE 204 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166855050 | ||||||||
| FaxNumber: | 6166853050 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 E DOWNING ST | ||||||||
| Address2: | |||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744643324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9918456064 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2007 | ||||||||
| LastUpdateDate: | 05/31/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 5101015360 | MI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 1932254745 | 05 | MI | MEDICAID |