Provider Demographics
NPI:1356319578
Name:GLICK, KENNETH ASHER (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ASHER
Last Name:GLICK
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 1:301 FIRST AVENUE
Mailing Address - Street 2:
Mailing Address - City:TARENTUM
Mailing Address - State:PA
Mailing Address - Zip Code:15084-1858
Mailing Address - Country:US
Mailing Address - Phone:724-224-3113
Mailing Address - Fax:724-224-2447
Practice Address - Street 1:301 1ST AVE
Practice Address - Street 2:
Practice Address - City:TARENTUM
Practice Address - State:PA
Practice Address - Zip Code:15084-1858
Practice Address - Country:US
Practice Address - Phone:412-000-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD030746E207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
10927561OtherCAQH
PA001218038Medicaid
PA110544Medicare PIN