MEDICARE: DR. MICHELLE J 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	2080A0000X	Pediatric Adolescent Medicine Physician	15752	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1659366854
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHELLE J GIBSON M.D.

Provider Business Mailing Address
First Line	:	5440 WATKINS DR
Second Line	:	SUITE B
City	:	JACKSON
State	:	MS
Zip	:	39206-2034
Country	:	US
Telephone Number	:	601-364-2726
Fax Number	:	601-364-2731

Provider Business Practice Location Address
First Line	:	5440 WATKINS DR
Second Line	:	SUITE B
City	:	JACKSON
State	:	MS
Zip	:	39206-2034
Country	:	US
Telephone Number	:	601-364-2726
Fax Number	:	601-364-2731

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

Provider Enumeration Date	:	09/13/2005
Last Update Date	:	08/12/2011

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