Provider Demographics
NPI:1215126925
Name:GIBBONS, MICHAEL T (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:GIBBONS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 DARROW RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:HUDSON
Mailing Address - State:OH
Mailing Address - Zip Code:44236-5026
Mailing Address - Country:US
Mailing Address - Phone:330-656-5911
Mailing Address - Fax:330-656-5901
Practice Address - Street 1:1296 TOD PL NW
Practice Address - Street 2:SUITE 200
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44485-2474
Practice Address - Country:US
Practice Address - Phone:330-656-5911
Practice Address - Fax:330-656-5901
Is Sole Proprietor?:No
Enumeration Date:2007-10-18
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-090557207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2811318Medicaid
OH000000381140OtherANTHEM
OH000000385524OtherANTHEM
OH000000028430OtherANTHEM
OH000000028430OtherANTHEM
OHGI4223521Medicare PIN
OHGI4223523Medicare PIN