MEDICARE: JACK MICHAEL GIBSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	036064619	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	007200621	OTHER	IL	BLUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1346235777
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK MICHAEL GIBSON M.D.

Provider Business Mailing Address
First Line	:	530 NE GLEN OAK AVE
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61637-0001
Country	:	US
Telephone Number	:	309-696-2297
Fax Number	:

Provider Business Practice Location Address
First Line	:	530 NE GLEN OAK AVE
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61637-0001
Country	:	US
Telephone Number	:	309-696-2297
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2005
Last Update Date	:	07/18/2019

Similar Medicare Providers

1730562950 — MEGHANA NADIGER M.D.
Practice Location Address:

530 NE GLEN OAK AVE BLDG ROOM5642
PEORIA, IL
61637-0001

Practice Phone: 812-341-9222
Practice Fax:

1427057595 — DAVID P CHAN MD
Practice Location Address:

420 NE GLEN OAK AVE
PEORIA, IL
61637-0001

Practice Phone: 309-655-3453
Practice Fax: 309-655-3410

1275535056 — MR. EDWARD C. RAINVILLE PHARMMS
Practice Location Address:

OSF SAINT FRANCIS MEDICAL CENTER- PHARMACY DEPT , 530 NE GLEN OAK AVE
PEORIA, IL
61637-0001

Practice Phone: 309-655-7331
Practice Fax: 309-655-4036

1801881446 — MISS CARA L PHILLIPS PHARMD
Practice Location Address:

530 NE GLEN OAK AVE
PEORIA, IL
61637-0001

Practice Phone: 309-655-2285
Practice Fax:

1285610311 — JENNIFER ELAINE BURTON MS, CGC
Practice Location Address:

UNIVERSITY OF ILLINOIS COLLEGE OF MEDICINE AT PEOR , 530 NE GLEN OAK AVE.
PEORIA, IL
61637-0001

Practice Phone: 309-624-9584
Practice Fax:

1902883648 — SAMIR SAXENA MD
Practice Location Address:

530 NE GLEN OAK AVE
PEORIA, IL
61637-0001

Practice Phone: 309-624-8818
Practice Fax: 309-624-8820

Directions to “ JACK MICHAEL GIBSON M.D.” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

Copyright © 2007-2026 (Powered by Swiss Vault Engine), all rights reserved. HIPAA liability, trademark, document use and software licensing rules apply. All registered trademarks, used in the content, are the property of their owners. Your interactions with this site are in accordance with our Terms of Use and Privacy Policy.