Provider Demographics
NPI:1295728327
Name:HARRISON, GWYN (MD)
Entity type:Individual
Prefix:
First Name:GWYN
Middle Name:
Last Name:HARRISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 W INDUSTRIAL BLVD
Mailing Address - Street 2:SUITE 18
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-4331
Mailing Address - Country:US
Mailing Address - Phone:301-777-7525
Mailing Address - Fax:301-777-0184
Practice Address - Street 1:1050 W INDUSTRIAL BLVD
Practice Address - Street 2:SUITE 18
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-4331
Practice Address - Country:US
Practice Address - Phone:301-777-7525
Practice Address - Fax:301-777-0184
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD33776174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD219775OtherMAMSI
PA4102OtherMEDICARE PTAN
MD219775OtherMDIPA, OPTIMUM CHOICE
MD4102OtherBLUE SHIELD OF MARYLAND
MD4667874OtherAETNA
WV0091154000Medicaid
MD408181100Medicaid
MD219775OtherALLIANCE
MD160004761OtherTRAVELERS MEDICARE PTAN