=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255533386
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LARRY GIDEON, M D
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 609 BUNNELL M 19
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-392-2192
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 609 BUNNELL M 19
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-392-2192
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | LARRY GIDEON
-----------------------------------------------------
Credential | M D
-----------------------------------------------------
Telephone | 810-392-2192
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | LG407549
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------