1639467442 NPI number — GORDON L. GIBSON, M. D., P. A.

Table of content: (NPI 1639467442)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639467442 NPI number — GORDON L. GIBSON, M. D., P. A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GORDON L. GIBSON, M. D., P. A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1639467442
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1190
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONWAY
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72033-1190
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-227-7499
Provider Business Mailing Address Fax Number:
501-504-2404

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
106 RIDGEWAY
Provider Second Line Business Practice Location Address:
SUITES A & B
Provider Business Practice Location Address City Name:
HOT SPRINGS
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71901-7157
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-321-0547
Provider Business Practice Location Address Fax Number:
501-321-0386
Provider Enumeration Date:
07/13/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MCNEAL
Authorized Official First Name:
KANDI
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
501-227-7499

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  C4484 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 104488001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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