MEDICARE: LILLIAN GIBB PT

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	PT3113	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962494229
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LILLIAN GIBB PT

Provider Business Mailing Address
First Line	:	1227 HWY 42
Second Line	:	SUITE 110
City	:	PETAL
State	:	MS
Zip	:	39465-2790
Country	:	US
Telephone Number	:	601-545-2728
Fax Number	:	601-545-2792

Provider Business Practice Location Address
First Line	:	1227 HWY 42
Second Line	:	SUITE 110
City	:	PETAL
State	:	MS
Zip	:	39465-2790
Country	:	US
Telephone Number	:	601-545-2728
Fax Number	:	601-545-2792

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

Provider Enumeration Date	:	08/22/2005
Last Update Date	:	11/17/2011

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Directions to “ LILLIAN GIBB PT” Practice Location

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