1841293891 NPI number — DR. ELMER RICKEY GIBBS M.D.

Employer Identification Number (EIN)	:
Provider Organization Name (Legal Business Name)	:
Provider Last Name (Legal Name)	:	GIBBS
Provider First Name	:	ELMER
Provider Middle Name	:	RICKEY
Provider Name Prefix Text	:	DR.
Provider Name Suffix Text	:
Provider Credential Text	:	M.D.
Provider Gender Code	:	M

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	:	1841293891
Entity Type Code	:	Individual
Replacement NPI	:
Last Update Date	:	06/16/2010
NPI Deactivation Reason Code	:
NPI Deactivation Date	:
NPI Reactivation Date	:

Provider First Line Business Mailing Address	:	1645 SOUTH MAIN ST. STE. 101
Provider Second Line Business Mailing Address	:
Provider Business Mailing Address City Name	:	CROSSVILLE
Provider Business Mailing Address State Name	:	TN
Provider Business Mailing Address Postal Code	:	38555
Provider Business Mailing Address Country Code	:	US
Provider Business Mailing Address Telephone Number	:	9314847531
Provider Business Mailing Address Fax Number	:	9314569515

Provider First Line Business Practice Location Address	:	1645 SOUTH MAIN ST. STE. 101
Provider Second Line Business Practice Location Address	:
Provider Business Practice Location Address City Name	:	CROSSVILLE
Provider Business Practice Location Address State Name	:	TN
Provider Business Practice Location Address Postal Code	:	38555
Provider Business Practice Location Address Country Code	:	US
Provider Business Practice Location Address Telephone Number	:	9314847531
Provider Business Practice Location Address Fax Number	:	9314569515
Provider Enumeration Date	:	05/23/2005

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

• Taxonomy code: 208G00000X , with the licence number:  35733 , registered in the state of TN .
• Taxonomy code: 208600000X , with the licence number: 35733 , registered in the state of TN .

• Identifier: 27-1779467 . This is a "TAX ID" identifier . This identifiers is of the category "".
• Identifier: 3382060 , issued by the state of ( TN ) . This identifiers is of the category "".
• Identifier: 3382060 , issued by the state of ( TN ) . This identifiers is of the category "".
• Identifier: 3877794 , issued by the state of ( TN ) . This identifiers is of the category "".
• Identifier: 4042486 . This is a "TENNCARE SELECT NUMBER" identifier , issued by the state of ( TN ) . This identifiers is of the category "".
• Identifier: 4252798 . This is a "BC/BS OF TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "".
• Identifier: H68773 , issued by the state of ( TN ) . This identifiers is of the category "".