Basic Information
| Provider Information | |||||||||
| NPI: | 1285167924 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIBERSON | ||||||||
| FirstName: | TYLER | ||||||||
| MiddleName: | ANDREW | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 49 JESSE HILL JR DR SE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303033049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042518865 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6 GLEN COVE DR | ||||||||
| Address2: | |||||||||
| City: | ROCKPORT | ||||||||
| State: | ME | ||||||||
| PostalCode: | 048564272 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073018000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2017 | ||||||||
| LastUpdateDate: | 07/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207P00000X | MD23966 | ME | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.