1912300377 NPI number — DR. KILEY COLEMAN GIBBS PT, DPT, MA, PCS

Table of content: DR. KILEY COLEMAN GIBBS PT, DPT, MA, PCS (NPI 1912300377)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912300377 NPI number — DR. KILEY COLEMAN GIBBS PT, DPT, MA, PCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GIBBS
Provider First Name:
KILEY
Provider Middle Name:
COLEMAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT, MA, PCS
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:
1912300377
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19208 DEER PATH
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KNOXVILLE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21758-1344
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
240-377-6179
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21631 RIDGETOP CIR STE 225A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STERLING
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20166
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-377-6179
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/30/2014

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: 2251P0200X , with the licence number:  2305211529 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2251P0200X , with the licence number: 26938 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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