Provider Demographics
NPI:1386840742
Name:GIBSON, SAMUEL W (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:W
Last Name:GIBSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1830
Mailing Address - Country:US
Mailing Address - Phone:608-251-6100
Mailing Address - Fax:608-826-2710
Practice Address - Street 1:700 S PARK ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1830
Practice Address - Country:US
Practice Address - Phone:608-251-6100
Practice Address - Fax:608-826-2710
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ686202085R0202X
MO20080115342085R0202X
WI526652085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1386840742Medicaid
004315045Medicare PIN
003927060Medicare PIN
WI1386840742Medicaid