Provider Demographics
NPI:1093873713
Name:MCKIBBEN, EVERETT C (MD)
Entity Type:Individual
Prefix:
First Name:EVERETT
Middle Name:C
Last Name:MCKIBBEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:EVERETT
Other - Middle Name:C
Other - Last Name:MCKIBBEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:THE LAIRD CLINIC
Mailing Address - Street 2:103 DOCTORS PARK
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759
Mailing Address - Country:US
Mailing Address - Phone:662-323-2515
Mailing Address - Fax:662-323-2557
Practice Address - Street 1:THE LAIRD CLINIC
Practice Address - Street 2:103 DOCTORS PARK
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759
Practice Address - Country:US
Practice Address - Phone:662-323-2515
Practice Address - Fax:662-323-2557
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12519208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00110394Medicaid
MS00110394Medicaid
080001431Medicare ID - Type Unspecified