Provider Demographics
NPI:1922147115
Name:MELVIN GLICK MD
Entity Type:Organization
Organization Name:MELVIN GLICK MD
Other - Org Name:FAMILY PRACTICE GERIATRIC MEDICINE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELVIN
Authorized Official - Middle Name:I
Authorized Official - Last Name:GLICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-246-2500
Mailing Address - Street 1:4475 LAWN AVE
Mailing Address - Street 2:
Mailing Address - City:WESTERN SPRINGS
Mailing Address - State:IL
Mailing Address - Zip Code:60558
Mailing Address - Country:US
Mailing Address - Phone:708-246-2500
Mailing Address - Fax:708-246-2785
Practice Address - Street 1:4475 LAWN AVE
Practice Address - Street 2:
Practice Address - City:WESTERN SPRINGS
Practice Address - State:IL
Practice Address - Zip Code:60558
Practice Address - Country:US
Practice Address - Phone:708-246-2500
Practice Address - Fax:708-246-2785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL570740Medicare ID - Type Unspecified