Provider Demographics
NPI:1548299159
Name:GIBBS, ROSE DELORES (MD)
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:DELORES
Last Name:GIBBS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461
Mailing Address - Country:US
Mailing Address - Phone:843-761-1995
Mailing Address - Fax:843-761-3257
Practice Address - Street 1:106 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461
Practice Address - Country:US
Practice Address - Phone:843-761-1995
Practice Address - Fax:843-761-3257
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7042207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCRHC038Medicaid
C611030281Medicare UPIN
423851Medicare ID - Type Unspecified