1164421442 NPI number — CAROL ANN JACKSON-GIBSON MD

Table of content: CAROL ANN JACKSON-GIBSON MD (NPI 1164421442)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164421442 NPI number — CAROL ANN JACKSON-GIBSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON-GIBSON
Provider First Name:
CAROL
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1164421442
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1150 YOUNGS RD
Provider Second Line Business Mailing Address:
SUITE 111
Provider Business Mailing Address City Name:
WILLIAMSVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14221-8053
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-688-7622
Provider Business Mailing Address Fax Number:
716-688-7592

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1150 YOUNGS RD
Provider Second Line Business Practice Location Address:
SUITE 111
Provider Business Practice Location Address City Name:
WILLIAMSVILLE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14221-8053
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-688-7622
Provider Business Practice Location Address Fax Number:
716-688-7592
Provider Enumeration Date:
07/19/2005

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: 2085N0904X , with the licence number:  176786 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 176786 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5609475 . This is a "INDEPENDENT HEALTH #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01598136 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000525515015 . This is a "BLUE CROSS WNY #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 150589FF . This is a "PREFERRED CARE-ROCHESTER" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 300118785 . This is a "RAILROAD MEDICARE #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: CR-DRA176786-2W . This is a "WORKERS COMPENSATION #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00025193901 . This is a "UNIVERA/EXCELLUS #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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