Basic Information
| Provider Information | |||||||||
| NPI: | 1245501378 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EDWARD D. GIBSON JR MD PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12241 LYNDELL PLANTATION DR | ||||||||
| Address2: | |||||||||
| City: | PANAMA CITY BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324072617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506249634 | ||||||||
| FaxNumber: | 8507692366 | ||||||||
| Practice Location | |||||||||
| Address1: | 1514 W 23RD ST STE A-4 | ||||||||
| Address2: | |||||||||
| City: | PANAMA CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324052905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506249634 | ||||||||
| FaxNumber: | 8507692366 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2012 | ||||||||
| LastUpdateDate: | 01/20/2012 | ||||||||
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| AuthorizedOfficialLastName: | GIBSON | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/ PHYSHIAN | ||||||||
| AuthorizedOfficialTelephone: | 8506249634 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | ME11148 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 53278 | 01 | FL | BCBS OF FLORIDA | OTHER | 56431100 | 05 | FL | MEDICAID |