Healthcare Provider Details

I. General information

NPI: 1700857414
Provider Name (Legal Business Name): MILES KENTON GIBSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 JOE T PETTY DR SUITE 300
RUSSELL SPRINGS KY
42642-8543
US

IV. Provider business mailing address

92 JOE T. PETTEY DR. SUITE 300
RUSSELL SPRINGS KY
42642
US

V. Phone/Fax

Practice location:
  • Phone: 270-866-7066
  • Fax: 270-866-7068
Mailing address:
  • Phone: 270-866-7066
  • Fax: 270-866-7068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number22156
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: