MEDICARE: DR. GWENNETH O CANCINO M.D.

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	D0046268	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	H9660002	OTHER	MD	CAREFIRST OF DC
2	53276204	OTHER	MD	CAREFIRST OF MD
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487657227
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GWENNETH O CANCINO M.D.

Provider Business Mailing Address
First Line	:	115 W BEL AIR AVENUE
Second Line	:
City	:	ABERDEEN
State	:	MD
Zip	:	21001-3221
Country	:	US
Telephone Number	:	410-272-1692
Fax Number	:	410-272-1694

Provider Business Practice Location Address
First Line	:	115 W BEL AIR AVENUE
Second Line	:
City	:	ABERDEEN
State	:	MD
Zip	:	21001-3221
Country	:	US
Telephone Number	:	410-272-3377
Fax Number	:	410-273-1479

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

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	11/08/2013

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