MEDICARE: DR. RUSSELL GIBSON 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	207Q00000X	Family Medicine Physician	MD18195	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0119209	OTHER	TN	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1821048638
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RUSSELL GIBSON MD

Provider Business Mailing Address
First Line	:	129 MONTGOMERY LN
Second Line	:
City	:	MARYVILLE
State	:	TN
Zip	:	37803-5649
Country	:	US
Telephone Number	:	865-681-1224
Fax Number	:	865-681-5185

Provider Business Practice Location Address
First Line	:	129 MONTGOMERY LN
Second Line	:
City	:	MARYVILLE
State	:	TN
Zip	:	37803-5649
Country	:	US
Telephone Number	:	865-681-1224
Fax Number	:	865-681-5185

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

Provider Enumeration Date	:	05/11/2006
Last Update Date	:	07/08/2007

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