Provider Demographics
NPI:1982648549
Name:GIBSON, SCOTT W (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:W
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 1:160 ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646-3808
Mailing Address - Country:US
Mailing Address - Phone:864-223-8090
Mailing Address - Fax:864-223-4026
Practice Address - Street 1:160 ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-3808
Practice Address - Country:US
Practice Address - Phone:864-223-8090
Practice Address - Fax:864-223-4026
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47438-020208600000X
SC85386208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1982648549Medicaid
WI60349OtherDEAN HEALTH INSURANCE
H33459Medicare UPIN
WI011957085Medicare PIN
WIP00260756Medicare PIN