Healthcare Provider Details

I. General information

NPI: 1639195944
Provider Name (Legal Business Name): RANDALL K GIBB MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 BELLEVUE AVE STE 400
SAINT LOUIS MO
63117-1858
US

IV. Provider business mailing address

1031 BELLEVUE AVE STE 400
SAINT LOUIS MO
63117-1858
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-7455
  • Fax: 314-977-7477
Mailing address:
  • Phone: 314-977-7455
  • Fax: 314-977-7477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number102525
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: