1619947157 NPI number — WILLIAM S GLICKFIELD MD

Table of content: WILLIAM S GLICKFIELD MD (NPI 1619947157)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619947157 NPI number — WILLIAM S GLICKFIELD MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GLICKFIELD
Provider First Name:
WILLIAM
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1619947157
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3170 KETTERING BLVD
Provider Second Line Business Mailing Address:
BUILDING B 3RD FLOOR
Provider Business Mailing Address City Name:
MORAINE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45439-1924
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-991-3188
Provider Business Mailing Address Fax Number:
937-223-9811

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3590 BUSENBARK RD STE 400
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRENTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45067-9602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-988-9243
Provider Business Practice Location Address Fax Number:
513-988-9369
Provider Enumeration Date:
01/26/2006

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: 207Q00000X , with the licence number:  35047466 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0486728 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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