Healthcare Provider Details

I. General information

NPI: 1790792539
Provider Name (Legal Business Name): BRIAN NEAL GLICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 08/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3022 WILLIAMS DR STE 300
FAIRFAX VA
22031-4600
US

IV. Provider business mailing address

611 S CARLIN SPRINGS RD SUITE 405
ARLINGTON VA
22204-1087
US

V. Phone/Fax

Practice location:
  • Phone: 703-573-9800
  • Fax: 703-573-2959
Mailing address:
  • Phone: 703-671-2490
  • Fax: 703-820-7207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number0101049247
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: