Provider Demographics
NPI:1477651958
Name:GLICK, MICHAEL E (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:E
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:LAHEY CLINIC
Mailing Address - Street 2:41 MALL ROAD
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805-0001
Mailing Address - Country:US
Mailing Address - Phone:781-744-8000
Mailing Address - Fax:781-744-5669
Practice Address - Street 1:LAHEY CLINIC
Practice Address - Street 2:41 MALL ROAD
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01805-0001
Practice Address - Country:US
Practice Address - Phone:781-744-8000
Practice Address - Fax:781-744-5669
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA39944207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110045439AMedicaid
MA110045439AMedicaid
MAJ0779101Medicare PIN