Healthcare Provider Details

I. General information

NPI: 1457450058
Provider Name (Legal Business Name): MARY CHRISTINA GLICK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 02/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 KATHERINE DRIVE SUITE B
FLOWOOD MS
39232
US

IV. Provider business mailing address

435 KATHERINE DRIVE SUITE B
FLOWOOD MS
39232
US

V. Phone/Fax

Practice location:
  • Phone: 601-932-6455
  • Fax: 601-981-7935
Mailing address:
  • Phone: 601-932-6455
  • Fax: 601-981-7935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number09307
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: