Provider Demographics
NPI:1598732539
Name:GLICK, CATHY LISA (MD)
Entity type:Individual
Prefix:
First Name:CATHY
Middle Name:LISA
Last Name:GLICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 PAGE AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2419
Mailing Address - Country:US
Mailing Address - Phone:517-205-1234
Mailing Address - Fax:
Practice Address - Street 1:309 PAGE AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-2419
Practice Address - Country:US
Practice Address - Phone:517-205-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301043978174400000X, 207RC0000X
MI043978207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M32310Medicare PIN
MI0M07480003Medicare PIN
MI0M32340Medicare PIN
MIB48166Medicare UPIN
MI0M32570Medicare PIN