Provider Demographics
NPI:1184612574
Name:GIBSON FOUNTAIN, CHERYL (MD)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:GIBSON FOUNTAIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43800 GARFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1136
Mailing Address - Country:US
Mailing Address - Phone:800-848-0202
Mailing Address - Fax:586-226-6949
Practice Address - Street 1:15050 E JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE PARK
Practice Address - State:MI
Practice Address - Zip Code:48230-2050
Practice Address - Country:US
Practice Address - Phone:313-823-4682
Practice Address - Fax:313-823-8022
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301052473207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700H249730OtherBCBS GROUP NUMBER
MI4502234Medicaid
MI4417616Medicaid
MI4417616Medicaid
MI4502234Medicaid