Basic Information
| Provider Information | |||||||||
| NPI: | 1871695783 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GIBALDI | ||||||||
| FirstName: | ANTHONY | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1239 | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480991239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488246600 | ||||||||
| FaxNumber: | 2483241477 | ||||||||
| Practice Location | |||||||||
| Address1: | 7350 INDUSTRIAL PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440605318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2167329480 | ||||||||
| FaxNumber: | 4409428431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2006 | ||||||||
| LastUpdateDate: | 05/05/2014 | ||||||||
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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 | 363L00000X | NP07009 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 2444260 | 05 | OH | MEDICAID |