Provider Demographics
NPI:1285828095
Name:JAMES A. GIBSON, M.D., P.C.
Entity Type:Organization
Organization Name:JAMES A. GIBSON, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RENE
Authorized Official - Middle Name:S
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-431-8592
Mailing Address - Street 1:5784 HIGHLAND RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-1876
Mailing Address - Country:US
Mailing Address - Phone:248-673-6667
Mailing Address - Fax:248-673-7234
Practice Address - Street 1:5784 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-1876
Practice Address - Country:US
Practice Address - Phone:248-673-6667
Practice Address - Fax:248-673-7224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-05
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301065590207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N83880Medicare PIN
MIG73046Medicare UPIN