1174609507 NPI number — ROBERT GLICKEN RPT

Table of content: ROBERT GLICKEN RPT (NPI 1174609507)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174609507 NPI number — ROBERT GLICKEN RPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLICKEN
Provider First Name:
ROBERT
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RPT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174609507
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
149-30 88 STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOWARD BEACH
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11414
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-835-6003
Provider Business Mailing Address Fax Number:
771-884-5077

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14930 88TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOWARD BEACH
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11414-1438
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-835-6003
Provider Business Practice Location Address Fax Number:
771-884-5077
Provider Enumeration Date:
10/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2251X0800X , with the licence number:  5041863 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4C8239 . This is a "HEALTHCARE PARTNERS" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: RG0Q601610 . This is a "BLUE CROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0070915 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 109542P . This is a "HIP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 15956 . This is a "VYTRA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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