Provider Demographics
NPI:1609874973
Name:GIBSON, GLEN R (MD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:R
Last Name:GIBSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 12622
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4017
Mailing Address - Country:US
Mailing Address - Phone:443-481-6538
Mailing Address - Fax:443-481-6515
Practice Address - Street 1:2003 MEDICAL PKWY
Practice Address - Street 2:SUITE 301
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-7992
Practice Address - Country:US
Practice Address - Phone:410-266-9966
Practice Address - Fax:410-266-6819
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00625502086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
2137029OtherMAMSI
64670901OtherBCBS
64670903OtherBCBS (HOS)
K5850009OtherBCBS DC
102077OtherJHHC
1703604OtherAMERICHOICE
2363265OtherUNITED HEALTHCARE
3758040OtherCIGNA
3943260OtherAETNA HMO
MD407175105Medicaid
254989OtherKAISER
7105042OtherAETNA PPO
287909OtherAMERIGROUP
145726104OtherFEDERAL WORKMAN'S COMP (ANNE ARUNDEL MEDICAL CENTER)
64670908OtherBCBS
MD407972800Medicaid
610307700OtherFEDERAL WORKMANS COMP
0001OtherBCBS
64670904OtherBCBS (HOS)
254989OtherKAISER
145726104OtherFEDERAL WORKMAN'S COMP (ANNE ARUNDEL MEDICAL CENTER)
610307700OtherFEDERAL WORKMANS COMP
148797ZADNMedicare PIN