MEDICARE: KENNETH ASHER GLICK MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0100X	Gastroenterology Physician	MD030746E	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10927561	OTHER		CAQH
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356319578
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH ASHER GLICK MD

Provider Business Mailing Address
First Line	:	301 FIRST AVENUE
Second Line	:
City	:	TARENTUM
State	:	PA
Zip	:	15084-1858
Country	:	US
Telephone Number	:	724-224-3113
Fax Number	:	724-224-2447

Provider Business Practice Location Address
First Line	:	301 1ST AVE
Second Line	:
City	:	TARENTUM
State	:	PA
Zip	:	15084-1858
Country	:	US
Telephone Number	:	412-000-0000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	11/16/2020

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