=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104077148
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES G. GIBBS JR. MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2008
-----------------------------------------------------
Last Update Date | 09/16/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 122 S COOK ST
-----------------------------------------------------
City | BENNETTSVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29512-3244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-454-1605
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 122 S COOK ST
-----------------------------------------------------
City | BENNETTSVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29512-3244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-454-1605
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | MD 4932
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | MD 2012-0064
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------