Healthcare Provider Details

I. General information

NPI: 1720388127
Provider Name (Legal Business Name): GLICK FAMILY MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2010
Last Update Date: 11/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41810 N VENTURE DR SUITE E-160
ANTHEM AZ
85086-3169
US

IV. Provider business mailing address

41810 N VENTURE DR SUITE E-160
ANTHEM AZ
85086-3169
US

V. Phone/Fax

Practice location:
  • Phone: 623-465-4627
  • Fax:
Mailing address:
  • Phone: 623-465-4627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5257
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4353
License Number StateAZ

VIII. Authorized Official

Name: BRYAN R GLICK
Title or Position: OWNER
Credential: DO
Phone: 623-465-4627