Provider Demographics
NPI:1447641592
Name:BRIAN T. MCKIBBEN, MD
Entity type:Organization
Organization Name:BRIAN T. MCKIBBEN, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTHCARE PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:MCKIBBEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-353-5921
Mailing Address - Street 1:1515 MAY ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4007
Mailing Address - Country:US
Mailing Address - Phone:904-353-5921
Mailing Address - Fax:904-353-5920
Practice Address - Street 1:1515 MAY ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4007
Practice Address - Country:US
Practice Address - Phone:904-353-5921
Practice Address - Fax:904-353-5920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-11
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME40936208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL050010100Medicaid
FLD51868Medicare UPIN
FL07162Medicare PIN