Basic Information
| Provider Information | |||||||||
| NPI: | 1144223215 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GLICK | ||||||||
| FirstName: | HAROLD | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11279 PERRY HWY | ||||||||
| Address2: | STE 450 | ||||||||
| City: | WEXFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150909303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7249331100 | ||||||||
| FaxNumber: | 7249331160 | ||||||||
| Practice Location | |||||||||
| Address1: | 6343 PENN AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152064010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4123632200 | ||||||||
| FaxNumber: | 4123632214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 03/25/2010 | ||||||||
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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 | 208000000X | MD010445E | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0006552440002 | 05 | PA | MEDICAID |