Basic Information
| Provider Information | |||||||||
| NPI: | 1013998202 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILLESPIE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10026 OLD OCEAN CITY BLVD | ||||||||
| Address2: | BUILDING ONE | ||||||||
| City: | BERLIN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218111288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106419109 | ||||||||
| FaxNumber: | 4106291203 | ||||||||
| Practice Location | |||||||||
| Address1: | 9733 HEALTHWAY DR | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218111155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106419109 | ||||||||
| FaxNumber: | 4106291203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 04/18/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | D0063904 | MD | Y | Allopathic & Osteopathic Physicians | Family Medicine | 208M00000X | D0063904 | MD | N | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 409649500 | 05 | MD | MEDICAID | 1000038891 | 05 | DE | MEDICAID |