Provider Demographics
NPI:1780267732
Name:GIBSON-O'GRADY, ALEC (MD)
Entity type:Individual
Prefix:DR
First Name:ALEC
Middle Name:
Last Name:GIBSON-O'GRADY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2586 DOUGLAS LN
Mailing Address - Street 2:
Mailing Address - City:THOMPSONS STATION
Mailing Address - State:TN
Mailing Address - Zip Code:37179-5029
Mailing Address - Country:US
Mailing Address - Phone:615-400-8683
Mailing Address - Fax:
Practice Address - Street 1:3990 JOHN R ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2018
Practice Address - Country:US
Practice Address - Phone:313-745-7233
Practice Address - Fax:313-993-3889
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program