Provider Demographics
NPI:1912984030
Name:GLICK, MARK R (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
Last Name:GLICK
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 1:775 NORMAN DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-7497
Mailing Address - Country:US
Mailing Address - Phone:717-274-5500
Mailing Address - Fax:717-202-0130
Practice Address - Street 1:775 NORMAN DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-7497
Practice Address - Country:US
Practice Address - Phone:717-274-5500
Practice Address - Fax:717-202-0130
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD037414E207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPO1680949OtherRAILROAD MEDICARE
PA0011222870004Medicaid
PA0011222870004Medicaid
PA146295Medicare PIN