Healthcare Provider Details

I. General information

NPI: 1922463231
Provider Name (Legal Business Name): JOHN GLICK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2015
Last Update Date: 11/27/2023
Certification Date: 09/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 E COUNTY LINE RD ST 1200
INDIANAPOLIS IN
46227-0963
US

IV. Provider business mailing address

6626 E 75TH ST SUITE 500
INDIANAPOLIS IN
46250-2805
US

V. Phone/Fax

Practice location:
  • Phone: 317-497-6270
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10001956A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: