Healthcare Provider Details

I. General information

NPI: 1417935990
Provider Name (Legal Business Name): GLENN GIDSEG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 08/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

365 STIRRUP KEY BLVD
MARATHON FL
33050-2943
US

IV. Provider business mailing address

365 STIRRUP KEY BLVD
MARATHON FL
33050-2943
US

V. Phone/Fax

Practice location:
  • Phone: 954-363-1011
  • Fax: 561-807-7836
Mailing address:
  • Phone: 954-363-1011
  • Fax: 954-531-0703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME30630
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: