Provider Demographics
NPI:1891864690
Name:GIPSON, THOMAS GRADY (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:GRADY
Last Name:GIPSON
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 1:511 PAINTED WOOD DR
Mailing Address - Street 2:
Mailing Address - City:SYKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21784-8020
Mailing Address - Country:US
Mailing Address - Phone:410-795-0782
Mailing Address - Fax:
Practice Address - Street 1:3001 S HANOVER ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21225-1233
Practice Address - Country:US
Practice Address - Phone:410-350-3360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0023545207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDIG03OtherMEDICARE GROUP NUMBER
MDW299Medicare ID - Type Unspecified
MDIG03OtherMEDICARE GROUP NUMBER