Healthcare Provider Details

I. General information

NPI: 1124136601
Provider Name (Legal Business Name): MELVIN I GLICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2006
Last Update Date: 11/23/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4475 LAWN AVE
WESTERN SPRINGS IL
60558-1283
US

IV. Provider business mailing address

4475 LAWN AVE
WESTERN SPRINGS IL
60558-1283
US

V. Phone/Fax

Practice location:
  • Phone: 708-246-2500
  • Fax: 708-246-2785
Mailing address:
  • Phone: 708-246-2500
  • Fax: 708-246-2785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number036057005
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: