Provider Demographics
NPI:1790044220
Name:AMBROSE, GINA (DO)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:AMBROSE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 MEDICAL PKWY
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3773
Mailing Address - Country:US
Mailing Address - Phone:443-481-1366
Mailing Address - Fax:
Practice Address - Street 1:2001 MEDICAL PARKWAY
Practice Address - Street 2:ANNE ARUNDEL MEDICAL CENTER
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401
Practice Address - Country:US
Practice Address - Phone:443-481-1366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-03
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0078884207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0007Medicaid