Basic Information
| Provider Information | |||||||||
| NPI: | 1235230269 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIBBS | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5301 VIRGINIA WAY STE 300 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370277542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152214474 | ||||||||
| FaxNumber: | 6152343774 | ||||||||
| Practice Location | |||||||||
| Address1: | 5301 VIRGINIA WAY STE 300 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370277542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152214474 | ||||||||
| FaxNumber: | 6152343774 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| 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 | 207ZP0102X | 15265 | TN | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 15291 | KY | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 01045587 | IN | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 4110190 | 01 | TN | BLUE CROSS | OTHER | 50010952 | 01 | KS | PASSPORT | OTHER | 3040447 | 05 | TN | MEDICAID | 64774821 | 05 | KY | MEDICAID |