Basic Information
| Provider Information | |||||||||
| NPI: | 1841207016 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GLICK | ||||||||
| FirstName: | PHILIP | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8000 DEPT 313 | ||||||||
| Address2: | UNIVERSITY AT BUFFALO SURGEONS, INC. | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142670002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168884889 | ||||||||
| FaxNumber: | 7168495620 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 HIGH ST | ||||||||
| Address2: | DEPT OF SURGERY | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142031126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168593371 | ||||||||
| FaxNumber: | 7168594580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 03/26/2014 | ||||||||
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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 | 2086S0120X | 175202 | NY | Y | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery |
ID Information
| ID | Type | State | Issuer | Description | 01084179 | 05 | NY | MEDICAID |