Healthcare Provider Details

I. General information

NPI: 1922147115
Provider Name (Legal Business Name): MELVIN GLICK MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4475 LAWN AVE
WESTERN SPRINGS IL
60558
US

IV. Provider business mailing address

4475 LAWN AVE
WESTERN SPRINGS IL
60558
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 Number
License Number StateIL

VIII. Authorized Official

Name: MRS. MELVIN I GLICK
Title or Position: OWNER
Credential: MD
Phone: 708-246-2500