Basic Information
| Provider Information | |||||||||
| NPI: | 1053308874 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIBBONS | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 402319 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303842319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797097399 | ||||||||
| FaxNumber: | 4797097053 | ||||||||
| Practice Location | |||||||||
| Address1: | 1480 W CENTER ST | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729363449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4799965585 | ||||||||
| FaxNumber: | 4799965386 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2005 | ||||||||
| LastUpdateDate: | 08/27/2010 | ||||||||
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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 | E3378 | AR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200004590A | 05 | OK | MEDICAID | 148914001 | 05 | AR | MEDICAID |