Healthcare Provider Details

I. General information

NPI: 1013909613
Provider Name (Legal Business Name): PAUL H GIBSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 08/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11188 TESSON FERRY ROAD SUITE 100
SAINT LOUIS MO
63123
US

IV. Provider business mailing address

11188 TESSON FERRY RD SUITE 100
SAINT LOUIS MO
63123-6962
US

V. Phone/Fax

Practice location:
  • Phone: 314-849-5300
  • Fax: 314-849-2014
Mailing address:
  • Phone: 314-849-5300
  • Fax: 314-849-2014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberMDR8115
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: