Healthcare Provider Details

I. General information

NPI: 1285167924
Provider Name (Legal Business Name): TYLER ANDREW GIBERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2017
Last Update Date: 07/09/2020
Certification Date: 07/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 GLEN COVE DR
ROCKPORT ME
04856-4272
US

IV. Provider business mailing address

49 JESSE HILL JR DR SE
ATLANTA GA
30303-3049
US

V. Phone/Fax

Practice location:
  • Phone: 207-301-8000
  • Fax:
Mailing address:
  • Phone: 404-251-8865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD23966
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: