Individual
JACK MICHAEL GIBSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
530 NE GLEN OAK AVE, PEORIA, IL 61637-0001
(309) 696-2297
Mailing address
530 NE GLEN OAK AVE, PEORIA, IL 61637-0001
(309) 696-2297
Taxonomy
Speciality
Code
Description
License number
State
207V00000X
Obstetrics & Gynecology Physician
Primary
036064619
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
007200621
BLUE CROSS BLUE SHIELD
IL
05
—
036064619
—
IL
Enumeration date
09/12/2005
Last updated
07/18/2019
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