Provider Demographics
NPI:1609063833
Name:MYRON L GLICK MD
Entity Type:Organization
Organization Name:MYRON L GLICK MD
Other - Org Name:JERICHO ROAD FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MYRON
Authorized Official - Middle Name:L
Authorized Official - Last Name:GLICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-881-6191
Mailing Address - Street 1:184 BARTON ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14213-1573
Mailing Address - Country:US
Mailing Address - Phone:716-881-6191
Mailing Address - Fax:716-881-6247
Practice Address - Street 1:184 BARTON ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14213-1573
Practice Address - Country:US
Practice Address - Phone:716-881-6191
Practice Address - Fax:716-881-6247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYAA0777Medicare PIN