=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477764876
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAVID A GLUCK MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2007
-----------------------------------------------------
Last Update Date | 09/09/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1841 BROADWAY RM 1011
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10023-7603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-333-5000
-----------------------------------------------------
Fax | 914-946-1278
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1841 BROADWAY RM 1011
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10023-7603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-333-5000
-----------------------------------------------------
Fax | 914-946-1278
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCOTR
-----------------------------------------------------
Name | DR. DAVID A GLUCK
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 212-333-5000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VG0400X
-----------------------------------------------------
Taxonomy Name | Gynecology Physician
-----------------------------------------------------
License Number | 108577
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------