Provider Demographics
NPI:1578671517
Name:GIBERT, STEPHEN P JR (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:P
Last Name:GIBERT
Suffix:JR
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 80883
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30608-0883
Mailing Address - Country:US
Mailing Address - Phone:706-549-8114
Mailing Address - Fax:706-549-7558
Practice Address - Street 1:18 RIVERBEND DR SW
Practice Address - Street 2:SUITE 120
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-6013
Practice Address - Country:US
Practice Address - Phone:706-378-1202
Practice Address - Fax:706-378-1204
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA075624208VP0014X
SC22773207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC227739Medicaid
SCH59583Medicare ID - Type Unspecified
SC227739Medicaid
GA202I099999Medicare PIN