Basic Information
| Provider Information | |||||||||
| NPI: | 1225144041 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLICKEN | ||||||||
| FirstName: | STEPHAN | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 783311 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191783311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4848844500 | ||||||||
| FaxNumber: | 4848840699 | ||||||||
| Practice Location | |||||||||
| Address1: | 564 W BROAD ST | ||||||||
| Address2: | |||||||||
| City: | HAZLETON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 182016108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705016400 | ||||||||
| FaxNumber: | 5704532353 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2006 | ||||||||
| LastUpdateDate: | 02/13/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 75192 | MA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | MD433646 | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1021155010001 | 05 | PA | MEDICAID | 3810012098 | 05 | WV | MEDICAID | 102115501-0005 | 05 | PA | MEDICAID | 2860426 | 05 | OH | MEDICAID |