Provider Demographics
NPI:1205911518
Name:GIPSON, STEPHEN LAVON (MD)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:LAVON
Last Name:GIPSON
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 1:6005 PARK AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-5215
Mailing Address - Country:US
Mailing Address - Phone:901-767-9500
Mailing Address - Fax:907-767-7324
Practice Address - Street 1:6005 PARK AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5215
Practice Address - Country:US
Practice Address - Phone:901-767-9500
Practice Address - Fax:907-767-7324
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD14982207LP2900X
TN0000014982208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN125345900OtherUS DEPT OF LABOR
4226549OtherAETNA
TN40796OtherBLUE CROSS OF TN
TN6527100001Medicare NSC
TN125345900OtherUS DEPT OF LABOR
4226549OtherAETNA
3724471Medicare ID - Type UnspecifiedGRP #