Provider Demographics
NPI:1316207020
Name:MICHELE ISAACS GLIKSMAN
Entity Type:Organization
Organization Name:MICHELE ISAACS GLIKSMAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE MEDICAL ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIONA
Authorized Official - Middle Name:
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-384-8310
Mailing Address - Street 1:155 N WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BERGENFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07621-1742
Mailing Address - Country:US
Mailing Address - Phone:201-384-8310
Mailing Address - Fax:201-384-1085
Practice Address - Street 1:155 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:BERGENFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07621-1742
Practice Address - Country:US
Practice Address - Phone:201-384-8310
Practice Address - Fax:201-384-1085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-29
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06064200173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJG11707Medicare UPIN
NJ514361Medicare PIN