MEDICARE: RANDAL BOYD GIBB MD

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	207Y00000X	Otolaryngology Physician	1650121205	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	870281028RG2	OTHER	UT	EMIA
2	10-00362	OTHER	UT	UNITED HEALTHCARE
3	107006654103	OTHER	UT	IHC
4	233116	OTHER	UT	ALTIUS
5	36245	OTHER	UT	DMBA
6	81445	OTHER	UT	PEHP
7	P00215615	OTHER	UT	PALMETTO

General Provider Information

NPI Number	:	1679675383
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RANDAL BOYD GIBB MD

Provider Business Mailing Address
First Line	:	1055 N 500 W
Second Line	:	CREDENTIALING DEPARTMENT
City	:	PROVO
State	:	UT
Zip	:	84604-3305
Country	:	US
Telephone Number	:	801-354-8225
Fax Number	:	801-418-0941

Provider Business Practice Location Address
First Line	:	820 S WOODLAND HILLS DR
Second Line	:
City	:	WOODLAND HILLS
State	:	UT
Zip	:	84653-2030
Country	:	US
Telephone Number	:	801-372-8314
Fax Number	:

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

Provider Enumeration Date	:	09/02/2006
Last Update Date	:	07/08/2020

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