Provider Demographics
NPI:1699830075
Name:GLICK, HYMAN
Entity Type:Individual
Prefix:
First Name:HYMAN
Middle Name:
Last Name:GLICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 BROOKLINE AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-3904
Mailing Address - Country:US
Mailing Address - Phone:617-654-7111
Mailing Address - Fax:617-421-1065
Practice Address - Street 1:133 BROOKLINE AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-3904
Practice Address - Country:US
Practice Address - Phone:617-654-7111
Practice Address - Fax:617-421-1065
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA35054204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2002078Medicaid
MAB206OtherHPHC
MA0014435OtherNHP
MAM08320OtherBCBS
MA705098OtherTUFTS
MA4414144-001OtherCIGNA
MA0014435OtherNHP
MA4414144-001OtherCIGNA