Provider Demographics
NPI:1053353268
Name:HIBBS, SUSAN GAYLE (MD)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:GAYLE
Last Name:HIBBS
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 1:4805 MONTGOMERY RD STE 150
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-2280
Mailing Address - Country:US
Mailing Address - Phone:513-961-5558
Mailing Address - Fax:
Practice Address - Street 1:4805 MONTGOMERY RD
Practice Address - Street 2:STE 410
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45212
Practice Address - Country:US
Practice Address - Phone:513-241-2370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI465872084N0400X
OH35.1387482084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34552200Medicaid
WI002071450OtherMEDICARE
WI5814580001Medicare NSC
WI34552200Medicaid
WI002045430Medicare ID - Type Unspecified