Healthcare Provider Details

I. General information

NPI: 1578671517
Provider Name (Legal Business Name): STEPHEN P GIBERT JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 03/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 RIVERBEND DR SW SUITE 120
ROME GA
30161-6013
US

IV. Provider business mailing address

PO BOX 80883
ATHENS GA
30608-0883
US

V. Phone/Fax

Practice location:
  • Phone: 706-378-1202
  • Fax: 706-378-1204
Mailing address:
  • Phone: 706-549-8114
  • Fax: 706-549-7558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number22773
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number22773
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number075624
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: