Healthcare Provider Details

I. General information

NPI: 1356732242
Provider Name (Legal Business Name): REBECCA ANN GLUCK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2015
Last Update Date: 10/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 N CHARLES ST
BALTIMORE MD
21218-4300
US

IV. Provider business mailing address

401 N MICHIGAN AVE SUITE 1200
CHICAGO IL
60611-4264
US

V. Phone/Fax

Practice location:
  • Phone: 410-554-6300
  • Fax: 410-554-3919
Mailing address:
  • Phone: 312-635-0973
  • Fax: 813-290-9691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0005673
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: