MEDICARE: KELLY BRUCE GIBSON DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT018276	OH

General Provider Information

NPI Number	:	1811521172
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY BRUCE GIBSON DPT

Provider Business Mailing Address
First Line	:	5000 ROCKSIDE RD STE 500
Second Line	:
City	:	INDEPENDENCE
State	:	OH
Zip	:	44131-2178
Country	:	US
Telephone Number	:	216-459-2846
Fax Number	:	216-901-2803

Provider Business Practice Location Address
First Line	:	5520 BROADVIEW RD FRNT
Second Line	:
City	:	PARMA
State	:	OH
Zip	:	44134-1606
Country	:	US
Telephone Number	:	216-749-6650
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/26/2020
Last Update Date	:	02/26/2020

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