Healthcare Provider Details

I. General information

NPI: 1104124221
Provider Name (Legal Business Name): KERRI LYN GIBSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2011
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 E COLLEGE AVE
BLOOMINGTON IL
61704-2101
US

IV. Provider business mailing address

1701 E COLLEGE AVE
BLOOMINGTON IL
61704-2101
US

V. Phone/Fax

Practice location:
  • Phone: 309-664-3000
  • Fax: 309-664-3026
Mailing address:
  • Phone: 309-664-3120
  • Fax: 309-663-5742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35.096519
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036177585
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: