Gibson, Jack Michael

Gibson, Jack Michael is an individual health care provider with primary practice located at 530 Ne Glen Oak Ave , Peoria IL 61637-0001. He recently has only one registered license in Allopathic & Osteopathic Physicians / Obstetrics & Gynecology, which is considered as his primary health care specialty. Gibson, Jack Michael can be contacted via phone (309) 696-2297.

Contact Information

Primary practice address
530 Ne Glen Oak Ave Peoria IL 61637-0001
Phone: (309) 696-2297
Fax:
Website:
Map and Directions

Health care specialties

SpecialtyCodeLicense #State
Allopathic & Osteopathic Physicians / Obstetrics & Gynecology 207V00000X 036064619 Illinois

Profile Details

NPI number 1346235777
LBN Legal business name Gibson, Jack Michael
Credentials Doctor of Medicine (MD)
Entity Individual
Sole proprietor 1 No
Enumeration date Sep 12th, 2005
Last updated Jul 18th, 2019 - about 7 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1346235777 NPPES
Illinois Other 007200621 BLUE CROSS BLUE SHIELD
Illinois MEDICAID 036064619 BLUE CROSS BLUE SHIELD

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