MEDICARE: GLENN GREGORY GIBBONS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	E3378	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053308874
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLENN GREGORY GIBBONS MD

Provider Business Mailing Address
First Line	:	811 N B ST
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72901-2129
Country	:	US
Telephone Number	:	479-480-4850
Fax Number	:	479-480-4833

Provider Business Practice Location Address
First Line	:	811 N B ST
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72901-2129
Country	:	US
Telephone Number	:	479-480-4850
Fax Number	:	479-480-4833

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/06/2005
Last Update Date	:	06/11/2025

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