Basic Information
| Provider Information | |||||||||
| NPI: | 1356399935 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLICK | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 FOULK ROAD | ||||||||
| Address2: | SUITE F | ||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 19810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026528990 | ||||||||
| FaxNumber: | 3026528646 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 FOULK ROAD | ||||||||
| Address2: | SUITE F | ||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 19810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026528990 | ||||||||
| FaxNumber: | 3026528646 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 07/16/2015 | ||||||||
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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 | 208800000X | C10002721 | DE | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 0000128201 | 05 | DE | MEDICAID |