1467416354 NPI number — H.P. GIBSON CRNA

Table of content: H.P. GIBSON CRNA (NPI 1467416354)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467416354 NPI number — H.P. GIBSON CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GIBSON
Provider First Name:
H.P.
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GIBSON
Provider Other First Name:
SAM
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1467416354
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3100 SPRING FOREST RD
Provider Second Line Business Mailing Address:
SUITE 130
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27616-2880
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-882-0705
Provider Business Mailing Address Fax Number:
919-873-9821

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
555 E CHEVES ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLORENCE
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29506-2617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-777-2000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/17/2006

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: 367500000X , with the licence number:  1-065636 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 2992 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 430036750 . This is a "PALMETTO" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 000029197 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 173758061A . This is a "CAID GA" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".