Provider Demographics
NPI:1699760629
Name:FRICK, GLEN S (MD, PHD)
Entity type:Individual
Prefix:MR
First Name:GLEN
Middle Name:S
Last Name:FRICK
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:495 E 4500 S
Mailing Address - Street 2:STE 200
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107
Mailing Address - Country:US
Mailing Address - Phone:801-595-8844
Mailing Address - Fax:801-506-0188
Practice Address - Street 1:495 E 4500 S
Practice Address - Street 2:STE 200
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107
Practice Address - Country:US
Practice Address - Phone:801-595-8844
Practice Address - Fax:801-506-0188
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-15
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD417392208000000X
UT10534932-1205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA10101276Medicaid
H99680Medicare UPIN