MEDICARE: DR. ELMER RICKEY GIBBS M.D.

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	208600000X	Surgery Physician	35733	TN
2	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician	35733	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	27-1779467	OTHER		TAX ID
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	4042486	OTHER	TN	TENNCARE SELECT NUMBER
4	4252798	OTHER	TN	BC/BS OF TN

General Provider Information

NPI Number	:	1841293891
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELMER RICKEY GIBBS M.D.

Provider Business Mailing Address
First Line	:	49 CLEVELAND ST 310
Second Line	:
City	:	CROSSVILLE
State	:	TN
Zip	:	38555-2854
Country	:	US
Telephone Number	:	931-787-1232
Fax Number	:	931-787-1228

Provider Business Practice Location Address
First Line	:	49 CLEVELAND ST 310
Second Line	:
City	:	CROSSVILLE
State	:	TN
Zip	:	38555-2854
Country	:	US
Telephone Number	:	931-787-1232
Fax Number	:	931-787-1228

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

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	01/21/2016

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