Provider Demographics
NPI:1346333895
Name:LARRY GIBSON, M.D., P.C.
Entity Type:Organization
Organization Name:LARRY GIBSON, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-954-9556
Mailing Address - Street 1:1709 VALLEY FORGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343
Mailing Address - Country:US
Mailing Address - Phone:423-954-9556
Mailing Address - Fax:423-954-9505
Practice Address - Street 1:2051 HAMILL ROAD
Practice Address - Street 2:#B
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343
Practice Address - Country:US
Practice Address - Phone:423-877-1212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3181502Medicaid
TN3074845OtherBLUECROSS/BLUESHIELD
B03979Medicare UPIN
TN3074845OtherBLUECROSS/BLUESHIELD