Basic Information
| Provider Information | |||||||||
| NPI: | 1609874973 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIBSON | ||||||||
| FirstName: | GLEN | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12622 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049154017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434816538 | ||||||||
| FaxNumber: | 4434816515 | ||||||||
| Practice Location | |||||||||
| Address1: | 2003 MEDICAL PKWY | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214017992 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102669966 | ||||||||
| FaxNumber: | 4102666819 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2005 | ||||||||
| LastUpdateDate: | 12/05/2013 | ||||||||
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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 | 2086X0206X | D0062550 | MD | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 2137029 | 01 | MAMSI | OTHER | 64670901 | 01 | BCBS | OTHER | 64670903 | 01 | BCBS (HOS) | OTHER | K5850009 | 01 | BCBS DC | OTHER | 102077 | 01 | JHHC | OTHER | 1703604 | 01 | AMERICHOICE | OTHER | 2363265 | 01 | UNITED HEALTHCARE | OTHER | 3758040 | 01 | CIGNA | OTHER | 3943260 | 01 | AETNA HMO | OTHER | 407175105 | 05 | MD | MEDICAID | 254989 | 01 | KAISER | OTHER | 7105042 | 01 | AETNA PPO | OTHER | 287909 | 01 | AMERIGROUP | OTHER | 145726104 | 01 | FEDERAL WORKMAN'S COMP (ANNE ARUNDEL MEDICAL CENTER) | OTHER | 64670908 | 01 | BCBS | OTHER | 407972800 | 05 | MD | MEDICAID | 610307700 | 01 | FEDERAL WORKMANS COMP | OTHER | 0001 | 01 | BCBS | OTHER | 64670904 | 01 | BCBS (HOS) | OTHER |