Provider Demographics
NPI:1912149790
Name:GLICKMAN, SAMUEL R (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:R
Last Name:GLICKMAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:25050 SE STARK STREET
Mailing Address - Street 2:LEGACY MT HOOD MULTISPECIALTY CLINIC
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030
Mailing Address - Country:US
Mailing Address - Phone:503-413-5702
Mailing Address - Fax:503-413-6499
Practice Address - Street 1:25050 SE STARK STREET
Practice Address - Street 2:LEGACY MT HOOD MULTISPECIALTY CLINIC
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030
Practice Address - Country:US
Practice Address - Phone:503-413-5702
Practice Address - Fax:503-413-6499
Is Sole Proprietor?:No
Enumeration Date:2009-03-25
Last Update Date:2016-08-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ORMD177588207RP1001X
NY265576208M00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program