Provider Demographics
NPI:1649217969
Name:GIBSON, MICHAEL KEVIN (MD PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KEVIN
Last Name:GIBSON
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3841 GREEN HILLS VILLAGE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-2691
Mailing Address - Country:US
Mailing Address - Phone:615-936-2000
Mailing Address - Fax:
Practice Address - Street 1:3601 THE VANDERBILT CLINIC
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37232-1716
Practice Address - Country:US
Practice Address - Phone:615-322-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN56792207R00000X, 207RX0202X
MDD54563207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD274901700Medicaid
OH2792894Medicaid
MDA26592Medicare UPIN
MDKR52D265Medicare ID - Type Unspecified
OH2792894Medicaid
OHH190840Medicare PIN