Provider Demographics
NPI:1013909613
Name:GIBSON, PAUL H (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:H
Last Name:GIBSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:11188 TESSON FERRY RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63123-6962
Mailing Address - Country:US
Mailing Address - Phone:314-849-5300
Mailing Address - Fax:314-849-2014
Practice Address - Street 1:11188 TESSON FERRY ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123
Practice Address - Country:US
Practice Address - Phone:314-849-5300
Practice Address - Fax:314-849-2014
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-19
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMDR8115207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
060012489OtherRR MCR
100777OtherHEALTHLINK
42440OtherGROUP HEALTH PLAN
2500159OtherUNITED HEALTH CARE
4061051OtherAETNA
MO21837OtherBLUE SHIELD BLUE CHOICE
MO201166410Medicaid
003010873Medicare PIN
42440OtherGROUP HEALTH PLAN