Provider Demographics
NPI:1427229582
Name:GIBSON, GARY (PT)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SEAGATE
Mailing Address - Street 2:SUITE 1960
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-1558
Mailing Address - Country:US
Mailing Address - Phone:419-247-2880
Mailing Address - Fax:
Practice Address - Street 1:4121 KING RD
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-4438
Practice Address - Country:US
Practice Address - Phone:419-517-8202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-17
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT11199225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1619980OtherBCBS OF IL
ILR02716Medicare PIN
IL568080Medicare PIN
IL567700Medicare PIN
ILR02715Medicare PIN
IL1619980OtherBCBS OF IL
IL568150Medicare PIN