Provider Demographics
NPI:1568513075
Name:GIBSON, RUSSELL EUGENE (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:EUGENE
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:PO BOX 1172
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37088-1172
Mailing Address - Country:US
Mailing Address - Phone:615-449-5771
Mailing Address - Fax:
Practice Address - Street 1:107 GLIDEPATH WAY
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37090-4133
Practice Address - Country:US
Practice Address - Phone:615-449-5771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-13
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010877992080S0012X
TN419912080S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080S0012XAllopathic & Osteopathic PhysiciansPediatricsSleep Medicine