Provider Demographics
NPI:1730308750
Name:ILENA J. BLICKER, MD, AMC
Entity Type:Organization
Organization Name:ILENA J. BLICKER, MD, AMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ILENA
Authorized Official - Middle Name:JOYCE
Authorized Official - Last Name:BLICKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-240-1677
Mailing Address - Street 1:435 ARDEN AVE
Mailing Address - Street 2:540
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-1130
Mailing Address - Country:US
Mailing Address - Phone:818-240-1677
Mailing Address - Fax:818-240-0147
Practice Address - Street 1:435 ARDEN AVE
Practice Address - Street 2:540
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-1130
Practice Address - Country:US
Practice Address - Phone:818-240-1677
Practice Address - Fax:818-240-0147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG194242084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG19424Medicare ID - Type Unspecified
CAA40641Medicare UPIN