Provider Demographics
NPI:1457450058
Name:GLICK, MARY CHRISTINA (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CHRISTINA
Last Name:GLICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:435 KATHERINE DRIVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232
Mailing Address - Country:US
Mailing Address - Phone:601-932-6455
Mailing Address - Fax:601-981-7935
Practice Address - Street 1:435 KATHERINE DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232
Practice Address - Country:US
Practice Address - Phone:601-932-6455
Practice Address - Fax:601-981-7935
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS093072080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0014803Medicaid
MS03521709Medicaid