Provider Demographics
NPI:1457322307
Name:GLICK, BENJAMIN (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:
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:PO BOX 206
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:01267
Mailing Address - Country:US
Mailing Address - Phone:413-458-8400
Mailing Address - Fax:
Practice Address - Street 1:71 HOSPITAL AVE
Practice Address - Street 2:NORTH ADAMS REGIONAL HOSPITAL LABORATORY
Practice Address - City:NORTH ADAMS
Practice Address - State:MA
Practice Address - Zip Code:01247
Practice Address - Country:US
Practice Address - Phone:413-664-5589
Practice Address - Fax:413-664-5698
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA34627207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2031276Medicaid
MAJ07052Medicare PIN
MA2031276Medicaid