Provider Demographics
NPI:1427016146
Name:TIBBS, PHILLIP A
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:A
Last Name:TIBBS
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 1:800 ROSE ST
Mailing Address - Street 2:MS 106
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-7001
Mailing Address - Country:US
Mailing Address - Phone:859-323-5661
Mailing Address - Fax:859-257-8902
Practice Address - Street 1:800 ROSE ST
Practice Address - Street 2:MS 106
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-7001
Practice Address - Country:US
Practice Address - Phone:859-323-5661
Practice Address - Fax:859-257-8902
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY17671207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64176712Medicaid
C64666Medicare UPIN
KY64176712Medicaid