MEDICARE: DR. GLENN G GABISAN 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	207X00000X	Orthopaedic Surgery Physician	MA069963	NJ
2	207XX0004X	Orthopaedic Foot and Ankle Surgery Physician	25MA06996300	NJ

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
5	CC3884	OTHER	NJ	RR MEDICARE GRP#
6	P00163993	OTHER	NJ	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7679694	OTHER	NJ	AETNA ID#
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	P3362517	OTHER	NJ	OXFORD ID#
7	J34051	OTHER	NJ	HEALTHNET ID#

General Provider Information

NPI Number	:	1346227428
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GLENN G GABISAN MD

Provider Business Mailing Address
First Line	:	776 SHREWSBURY AVE
Second Line	:	SUITE 201
City	:	TINTON FALLS
State	:	NJ
Zip	:	07724-3006
Country	:	US
Telephone Number	:	732-530-4949
Fax Number	:	732-530-3618

Provider Business Practice Location Address
First Line	:	776 SHREWSBURY AVE
Second Line	:	SUITE 201
City	:	TINTON FALLS
State	:	NJ
Zip	:	07724-3006
Country	:	US
Telephone Number	:	732-530-4949
Fax Number	:	732-530-3618

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

Provider Enumeration Date	:	12/29/2005
Last Update Date	:	12/04/2017

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