Basic Information
| Provider Information | |||||||||
| NPI: | 1306866074 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIBBS | ||||||||
| FirstName: | GRACE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1720 NICHOLASVILLE RD | ||||||||
| Address2: | SUITE 702 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405031404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592648811 | ||||||||
| FaxNumber: | 8592648822 | ||||||||
| Practice Location | |||||||||
| Address1: | 1720 NICHOLASVILLE RD | ||||||||
| Address2: | SUITE 702 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405031404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592648811 | ||||||||
| FaxNumber: | 8592648822 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 07/22/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0000X | 5101015015 | MI | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics |
ID Information
| ID | Type | State | Issuer | Description | 160C311260 | 01 | MI | BCBSM CHOICE BCN COM BLUE | OTHER | 1020336 | 01 | MI | MHP HAN | OTHER | 4865240 | 05 | MI | MEDICAID | 7100349070 | 05 | KY | MEDICAID | 0700532 | 01 | MI | PHP | OTHER |