MEDICARE: DR. ERIC JON RAINEY GIBSON

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	HSP00445	IA
2	103TC0700X	Clinical Psychologist	00966	IA
3	103TC2200X	Clinical Child & Adolescent Psychologist	HSP00445	IA
4	103TC2200X	Clinical Child & Adolescent Psychologist	00966	IA
5	103T00000X	Psychologist	HSP00445	IA
6	103T00000X	Psychologist	00966	IA

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	36432	OTHER	IA	BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	IA0134	OTHER	IA	JOHN DEERE HC

NPI Number	:	1528036761
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ERIC JON RAINEY GIBSON

Provider Business Mailing Address
First Line	:	1003 GRAND AVENUE
Second Line	:
City	:	WEST DES MOINES
State	:	IA
Zip	:	50265-3502
Country	:	US
Telephone Number	:	515-267-1003
Fax Number	:	515-267-0100

Provider Business Practice Location Address
First Line	:	1003 GRAND AVENUE
Second Line	:
City	:	WEST DES MOINES
State	:	IA
Zip	:	50265-3502
Country	:	US
Telephone Number	:	515-267-1003
Fax Number	:	515-267-0100

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

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	09/11/2025

2101 E JEFFERSON ST PPQA MEDICARE COMPLIANCE UNT 6 WEST , KAISER PERMANENTE MID ATLANTIC PERMANENTE MEDICAL GROUP
ROCKVILLE, MD
20852-4908

Practice Phone: 301-816-6660
Practice Fax: 301-816-6308

1003 GRAND AVE
WEST DES MOINES, IA
50265-3502