1124077136 NPI number — MRS. MICHELLE BENDER GIBSON NP

Table of content: MRS. MICHELLE BENDER GIBSON NP (NPI 1124077136)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124077136 NPI number — MRS. MICHELLE BENDER GIBSON NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GIBSON
Provider First Name:
MICHELLE
Provider Middle Name:
BENDER
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

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:
1124077136
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2232 WILBORN AVE, SUITE D
Provider Second Line Business Mailing Address:
HEMATOLOGY ONCOLOGY PRACTICE OF SOUTHSIDE VA, PC
Provider Business Mailing Address City Name:
SOUTH BOSTON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24592-1662
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
434-575-1212
Provider Business Mailing Address Fax Number:
434-575-1130

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2232 WILBORN AVE, SUITE D
Provider Second Line Business Practice Location Address:
HEMATOLOGY ONCOLOGY PRACTICE OF SOUTHSIDE VA, PC
Provider Business Practice Location Address City Name:
SOUTH BOSTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24592-1662
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-575-1212
Provider Business Practice Location Address Fax Number:
434-575-1130
Provider Enumeration Date:
05/08/2006

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: 363L00000X , with the licence number:  0017137534 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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