Provider Demographics
NPI:1225144041
Name:GLICKEN, STEPHAN R (MD)
Entity Type:Individual
Prefix:
First Name:STEPHAN
Middle Name:R
Last Name:GLICKEN
Suffix:
Gender:M
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:PO BOX 783311
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-3311
Mailing Address - Country:US
Mailing Address - Phone:484-884-4500
Mailing Address - Fax:484-884-0699
Practice Address - Street 1:564 W BROAD ST
Practice Address - Street 2:
Practice Address - City:HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18201-6108
Practice Address - Country:US
Practice Address - Phone:570-501-6400
Practice Address - Fax:570-453-2353
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA75192208000000X
PAMD433646208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1021155010001Medicaid
WV3810012098Medicaid
PA102115501-0005Medicaid
OH2860426Medicaid