Basic Information
| Provider Information | |||||||||
| NPI: | 1215973409 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIBBS | ||||||||
| FirstName: | DENIS | ||||||||
| MiddleName: | LAUREL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 777 RIVERVIEW DR | ||||||||
| Address2: | SUITE D208 | ||||||||
| City: | BENTON HARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490225065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699271248 | ||||||||
| FaxNumber: | 2699271701 | ||||||||
| Practice Location | |||||||||
| Address1: | 1234 NAPIER AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490852112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699838300 | ||||||||
| FaxNumber: | 2699836965 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 5315009276 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 4791852 | 05 | MI | MEDICAID | P00241412 | 01 | RAILROAD MEDICARE | OTHER |