Healthcare Provider Details

I. General information

NPI: 1326367038
Provider Name (Legal Business Name): NICHOLAS GLASS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2010
Last Update Date: 07/15/2022
Certification Date: 07/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2502 E STRATFORD CT
MILWAUKEE WI
53211-2634
US

IV. Provider business mailing address

2502 E STRATFORD CT
MILWAUKEE WI
53211-2634
US

V. Phone/Fax

Practice location:
  • Phone: 402-415-6110
  • Fax:
Mailing address:
  • Phone: 402-415-6110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4310-850
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number61298-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: