Provider Demographics
NPI:1124271994
Name:GARY L GLICK MD PA
Entity type:Organization
Organization Name:GARY L GLICK MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:GLICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-672-6100
Mailing Address - Street 1:4308 ALTON RD
Mailing Address - Street 2:SUITE 410
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33140-2840
Mailing Address - Country:US
Mailing Address - Phone:305-672-6100
Mailing Address - Fax:305-532-7444
Practice Address - Street 1:4308 ALTON RD
Practice Address - Street 2:SUITE 410
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33140-2840
Practice Address - Country:US
Practice Address - Phone:305-672-6100
Practice Address - Fax:305-532-7444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-24
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBB945Medicare PIN