Provider Demographics
NPI:1225045503
Name:GIBSON, KOSKIE
Entity Type:Individual
Prefix:
First Name:KOSKIE
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22971 HIGHWAY 76 E
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:SC
Mailing Address - Zip Code:29325-7529
Mailing Address - Country:US
Mailing Address - Phone:864-833-3046
Mailing Address - Fax:864-833-7323
Practice Address - Street 1:105 PHYSICIANS PARK DR
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:SC
Practice Address - Zip Code:29325-7551
Practice Address - Country:US
Practice Address - Phone:864-938-0111
Practice Address - Fax:864-938-0811
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2672225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ343714272Medicare PIN
SC0212480001Medicare NSC