Provider Demographics
NPI:1487748331
Name:GIBSON, RODNEY T (PT, PED)
Entity type:Individual
Prefix:MR
First Name:RODNEY
Middle Name:T
Last Name:GIBSON
Suffix:
Gender:M
Credentials:PT, PED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 NORTHSIDE DR E
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-1096
Mailing Address - Country:US
Mailing Address - Phone:912-764-4141
Mailing Address - Fax:912-764-2247
Practice Address - Street 1:146 NORTHSIDE DR E
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-1096
Practice Address - Country:US
Practice Address - Phone:912-764-4141
Practice Address - Fax:912-764-2247
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT002269225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000879623AMedicaid
GA58-1838574OtherTAX PROVIDER NUMBER
GAACS157060500OtherOWCP PROVIDER NUMBER
GA511I650155Medicare PIN
GAACS157060500OtherOWCP PROVIDER NUMBER