Provider Demographics
NPI:1790725422
Name:GIBSON, GINGER (PT)
Entity Type:Individual
Prefix:
First Name:GINGER
Middle Name:
Last Name:GIBSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 GRACELAND BLVD STE 327
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-1530
Mailing Address - Country:US
Mailing Address - Phone:312-399-4090
Mailing Address - Fax:877-967-5759
Practice Address - Street 1:118 GRACELAND BLVD STE 327
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-1530
Practice Address - Country:US
Practice Address - Phone:877-967-5769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070016321225100000X
OHPT011193225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00624021OtherMEDICARE RAIL ROAD
ILBCBS OF ILOther1619980
ILCD3789OtherMEDICARE RAIL ROAD GROUP
ILR02806Medicare PIN
IL567700Medicare PIN
ILP00624021OtherMEDICARE RAIL ROAD
ILBCBS OF ILOther1619980
ILR02805Medicare PIN
ILR02804Medicare PIN