1578507596 NPI number — JACKSON V GIBSON MD

Table of content: JACKSON V GIBSON MD (NPI 1578507596)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578507596 NPI number — JACKSON V GIBSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GIBSON
Provider First Name:
JACKSON
Provider Middle Name:
V
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578507596
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
205 PAGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PINEHURST
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28374-8798
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-295-5511
Provider Business Mailing Address Fax Number:
910-420-1608

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 REGIONAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PINEHURST
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28374-8850
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-255-4400
Provider Business Practice Location Address Fax Number:
910-420-1608
Provider Enumeration Date:
06/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  27189 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: FH1000130 . This is a "FIRSTCAROLINACARE PROV.#" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 8935323 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110081949 . This is a "PALMETTO GBA PROVIDER#" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: Q27189 . This is a "SC MEDICAID PROVIDER#" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 35323 . This is a "BC/BS NC PROVIDER#" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 0401871 . This is a "EVERCARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 80140 . This is a "MEDCOST PROVIDER#" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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