Healthcare Provider Details

I. General information

NPI: 1831139450
Provider Name (Legal Business Name): JILL GLICK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 04/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 EAST PARKWAY DRIVE
BALTIMORE MD
21218
US

IV. Provider business mailing address

1000 RIVER RD SUITE 100
CONSHOHOCKEN PA
19428-2439
US

V. Phone/Fax

Practice location:
  • Phone: 410-554-2000
  • Fax:
Mailing address:
  • Phone: 800-355-3818
  • Fax: 610-834-2862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0003037
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: