1013909613 NPI number — PAUL H GIBSON MD

Table of content: PAUL H GIBSON MD (NPI 1013909613)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013909613 NPI number — PAUL H GIBSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GIBSON
Provider First Name:
PAUL
Provider Middle Name:
H
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:
1013909613
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/30/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11188 TESSON FERRY RD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63123-6962
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-849-5300
Provider Business Mailing Address Fax Number:
314-849-2014

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11188 TESSON FERRY ROAD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63123
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-849-5300
Provider Business Practice Location Address Fax Number:
314-849-2014
Provider Enumeration Date:
08/19/2005

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: 207RI0011X , with the licence number:  MDR8115 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 060012489 . This is a "RR MCR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100777 . This is a "HEALTHLINK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 42440 . This is a "GROUP HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2500159 . This is a "UNITED HEALTH CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4061051 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 21837 . This is a "BLUE SHIELD BLUE CHOICE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 201166410 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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