Provider Demographics
NPI:1255337671
Name:GLINICK, STEPHEN ERNEST (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:ERNEST
Last Name:GLINICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:593 EDDY ST BLDG APC -10
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4923
Mailing Address - Country:US
Mailing Address - Phone:401-444-7959
Mailing Address - Fax:401-444-7144
Practice Address - Street 1:593 EDDY ST BLDG APC -10
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-444-7959
Practice Address - Fax:401-444-7144
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD5263207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9001492Medicaid
RIC90198Medicare UPIN