Healthcare Provider Details

I. General information

NPI: 1225144041
Provider Name (Legal Business Name): STEPHAN R GLICKEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 02/13/2020
Certification Date: 02/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

564 W BROAD ST
HAZLETON PA
18201-6108
US

IV. Provider business mailing address

PO BOX 783311
PHILADELPHIA PA
19178-3311
US

V. Phone/Fax

Practice location:
  • Phone: 570-501-6400
  • Fax: 570-453-2353
Mailing address:
  • Phone: 484-884-4500
  • Fax: 484-884-0699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number75192
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD433646
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1021155010001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 2
Identifier3810012098
Identifier TypeMEDICAID
Identifier StateWV
Identifier Issuer
# 3
Identifier102115501-0005
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 4
Identifier2860426
Identifier TypeMEDICAID
Identifier StateOH
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: