Provider Demographics
NPI:1982742920
Name:GLICK, ROBERT S (DPM)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:S
Last Name:GLICK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 W 18TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-2817
Mailing Address - Country:US
Mailing Address - Phone:312-243-3131
Mailing Address - Fax:
Practice Address - Street 1:1630 W 18TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-2817
Practice Address - Country:US
Practice Address - Phone:312-243-3131
Practice Address - Fax:312-666-2289
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016002695213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016002695Medicaid
520920Medicare ID - Type Unspecified
IL016002695Medicaid