Provider Demographics
NPI:1538479043
Name:GIBSON, RUSSELL SCOTT (MR)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:SCOTT
Last Name:GIBSON
Suffix:
Gender:M
Credentials:MR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:117 DOVECOT DR
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-8541
Mailing Address - Country:US
Mailing Address - Phone:478-442-4606
Mailing Address - Fax:
Practice Address - Street 1:1504 HARDEMAN AVE
Practice Address - Street 2:SUITE B
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-1441
Practice Address - Country:US
Practice Address - Phone:478-745-3135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-18
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3644912471M1202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471M1202XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMagnetic Resonance Imaging