Provider Demographics
NPI:1871695783
Name:GIBALDI, ANTHONY (NP)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:GIBALDI
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1239
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48099-1239
Mailing Address - Country:US
Mailing Address - Phone:248-824-6600
Mailing Address - Fax:248-324-1477
Practice Address - Street 1:7350 INDUSTRIAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-5318
Practice Address - Country:US
Practice Address - Phone:216-732-9480
Practice Address - Fax:440-942-8431
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP07009363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2444260Medicaid
OHNP13674Medicare PIN
P96915Medicare UPIN