Provider Demographics
NPI:1831191527
Name:FITZGERALD, MICHAEL GLEN (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GLEN
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 LOWNDES HILL RD BLDG 1
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-2101
Mailing Address - Country:US
Mailing Address - Phone:800-967-2289
Mailing Address - Fax:855-462-9736
Practice Address - Street 1:520 E 6TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4527
Practice Address - Country:US
Practice Address - Phone:800-967-2289
Practice Address - Fax:855-462-9736
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4644174400000X
TXG5044207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD67611Medicaid
AKMD67611Medicaid
AK460463837OtherTAX ID NUMBER
AK152808Medicare ID - Type UnspecifiedMEDICARE