Basic Information
| Provider Information | |||||||||
| NPI: | 1124027727 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLICKMAN | ||||||||
| FirstName: | JOEL | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 CIVIC CENTER BLVD | ||||||||
| Address2: | 1ST FLOOR, SUITE 300 S | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191044306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156622638 | ||||||||
| FaxNumber: | 2153495703 | ||||||||
| Practice Location | |||||||||
| Address1: | 3400 CIVIC CENTER BLVD | ||||||||
| Address2: | 1ST FLOOR, SUITE 300 S | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191044306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156622638 | ||||||||
| FaxNumber: | 2153495703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2005 | ||||||||
| LastUpdateDate: | 09/02/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 044118L | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RN0300X | MD044118L | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 670719 | 01 | BLUE CROSS/BLUE SHIELD | OTHER | 0000125516705 | 05 | PA | MEDICAID |