Healthcare Provider Details

I. General information

NPI: 1336120062
Provider Name (Legal Business Name): TIMOTHY E GIBSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 11/08/2020
Certification Date: 11/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 LAKE AVE N DEPARTMENT OF PEDIATRIC HOSPITALIST MEDICINE
WORCESTER MA
01655-0002
US

IV. Provider business mailing address

PO BOX 415348
BOSTON MA
02241-0001
US

V. Phone/Fax

Practice location:
  • Phone: 508-856-3590
  • Fax: 508-856-7989
Mailing address:
  • Phone: 800-225-8885
  • Fax: 508-334-1977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number212163
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number212163
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier110005892A
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer
# 2
IdentifierA3400004
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerMEDICARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: