Provider Demographics
NPI:1831139450
Name:GLICK, JILL (PA)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:GLICK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 RIVER RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CONSHOHOCKEN
Mailing Address - State:PA
Mailing Address - Zip Code:19428-2439
Mailing Address - Country:US
Mailing Address - Phone:800-355-3818
Mailing Address - Fax:610-834-2862
Practice Address - Street 1:201 EAST PARKWAY DRIVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21218
Practice Address - Country:US
Practice Address - Phone:410-554-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003037363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDN180Medicare ID - Type Unspecified
MD761LN180Medicare PIN