Provider Demographics
NPI:1558339606
Name:GLICK, LESLIE H (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:H
Last Name:GLICK
Suffix:
Gender:F
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 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:812-496-8780
Mailing Address - Fax:812-537-5826
Practice Address - Street 1:606 WILSON CREEK RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:IN
Practice Address - Zip Code:47025-1095
Practice Address - Country:US
Practice Address - Phone:812-496-8780
Practice Address - Fax:812-537-5826
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01050774A208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000355511OtherANTHEM IN OH KY
P00206914OtherRAILROAD MEDICARE
2518026OtherUNITED HEALTHCARE
IN200226980Medicaid
P00206914OtherRAILROAD MEDICARE
P00206914Medicare PIN
IN172580VMedicare PIN