Provider Demographics
NPI:1164620308
Name:GLICK, BRYAN R (DO)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:R
Last Name:GLICK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:7659 E PINNACLE PEAK RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-6297
Mailing Address - Country:US
Mailing Address - Phone:480-222-4600
Mailing Address - Fax:480-222-4619
Practice Address - Street 1:7659 E PINNACLE PEAK RD
Practice Address - Street 2:SUITE 105
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255-6297
Practice Address - Country:US
Practice Address - Phone:480-222-4600
Practice Address - Fax:480-222-4619
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-10
Last Update Date:2021-10-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ005257207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ157440Medicare PIN