Provider Demographics
NPI:1639352784
Name:MICHELLE J. GIBSON, MD PLLC
Entity Type:Organization
Organization Name:MICHELLE J. GIBSON, MD PLLC
Other - Org Name:THE KIDZ CARE KLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:JEANETTE
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-364-2726
Mailing Address - Street 1:5440 WATKINS DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-2034
Mailing Address - Country:US
Mailing Address - Phone:601-364-2726
Mailing Address - Fax:601-364-2731
Practice Address - Street 1:5440 WATKINS DR
Practice Address - Street 2:SUITE B
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-2034
Practice Address - Country:US
Practice Address - Phone:601-364-2726
Practice Address - Fax:601-364-2731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-12
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15752261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00524231Medicaid