1609874973 NPI number — DR. GLEN R GIBSON MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609874973 NPI number — DR. GLEN R GIBSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GIBSON
Provider First Name:
GLEN
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
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:
1609874973
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/05/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 12622
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELFAST
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04915-4017
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-481-6538
Provider Business Mailing Address Fax Number:
443-481-6515

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2003 MEDICAL PKWY
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
ANNAPOLIS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21401-7992
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-266-9966
Provider Business Practice Location Address Fax Number:
410-266-6819
Provider Enumeration Date:
07/12/2005

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: 2086X0206X , with the licence number:  D0062550 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2137029 . This is a "MAMSI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 64670901 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 64670903 . This is a "BCBS (HOS)" identifier . This identifiers is of the category "OTHER".
  • Identifier: K5850009 . This is a "BCBS DC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 102077 . This is a "JHHC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1703604 . This is a "AMERICHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2363265 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3758040 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3943260 . This is a "AETNA HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 407175105 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 254989 . This is a "KAISER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7105042 . This is a "AETNA PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 287909 . This is a "AMERIGROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 145726104 . This is a "FEDERAL WORKMAN'S COMP (ANNE ARUNDEL MEDICAL CENTER)" identifier . This identifiers is of the category "OTHER".
  • Identifier: 64670908 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 407972800 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 610307700 . This is a "FEDERAL WORKMANS COMP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0001 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 64670904 . This is a "BCBS (HOS)" identifier . This identifiers is of the category "OTHER".




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