Provider Demographics
NPI:1932176195
Name:GANGI, GLENN ROSS (MD)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:ROSS
Last Name:GANGI
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:MANAGED CARE DEPT
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:2835 E HWY 76
Practice Address - Street 2:STE 3
Practice Address - City:MULLINS
Practice Address - State:SC
Practice Address - Zip Code:29574
Practice Address - Country:US
Practice Address - Phone:843-423-0230
Practice Address - Fax:843-423-0802
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2016-12-29
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Provider Licenses
StateLicense IDTaxonomies
SC17068208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7905534Medicaid
SCG1521Medicaid
SC0930136OtherCIGNA
SC000000206904OtherUNISON HEALTH PLAN
SC4241328OtherAETNA
SC776932OtherWELLCARE
SCP00360556OtherRAILROAD MEDICARE
SCGP4522Medicaid
SCT10681Medicaid
NC2199551AOtherCIGNA MEDICARE
SC80023027OtherSELECT HEALTH
NC7905534Medicaid
SCE831128568Medicare PIN
SCP00360556OtherRAILROAD MEDICARE