Provider Demographics
NPI:1386836062
Name:ROGER O. GIBSON MD PC
Entity Type:Organization
Organization Name:ROGER O. GIBSON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:O
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:901-751-0150
Mailing Address - Street 1:1374 CORDOVA CV
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-2200
Mailing Address - Country:US
Mailing Address - Phone:901-751-0150
Mailing Address - Fax:901-751-1419
Practice Address - Street 1:1374 CORDOVA CV
Practice Address - Street 2:SUITE 102
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-2200
Practice Address - Country:US
Practice Address - Phone:901-751-0150
Practice Address - Fax:901-751-1419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-15
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10277207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08560OtherSTATE OF MISSISSIPPI BOARD OF LICENSE REGISTRATION
MS08560OtherSTATE OF MISSISSIPPI BOARD OF LICENSE REGISTRATION