Provider Demographics
NPI:1043706823
Name:MICHAEL GIBSON
Entity Type:Organization
Organization Name:MICHAEL GIBSON
Other - Org Name:SPECIALTY TRANSPORTATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:TURNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-300-2110
Mailing Address - Street 1:PO BOX 202
Mailing Address - Street 2:
Mailing Address - City:SNEEDVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37869-0202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:194 JONES RD
Practice Address - Street 2:
Practice Address - City:SNEEDVILLE
Practice Address - State:TN
Practice Address - Zip Code:37869-3639
Practice Address - Country:US
Practice Address - Phone:423-300-2110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-05
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ018573Medicaid