Tyler Patrick McKibben, MD

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

125086259 Issued in IL

Practice address

300 W Oak St Ste 200
Carbondale, IL 62901-1400

Phone

(618) 536-6621

NPI assigned

Jan 16, 2025

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Enrolled in IL

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Madison Medical Center Stockhoff Memorial Nursing Home

  • Critical Access Hospital
  • Fredericktown, MO
  • NPI 1720163025
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1736985600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1751932800000",
    "number": "1083425243",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "300 W OAK ST STE 200",
            "city": "CARBONDALE",
            "state": "IL",
            "postal_code": "629011400",
            "telephone_number": "618-536-6621"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "300 W OAK ST STE 200",
            "city": "CARBONDALE",
            "state": "IL",
            "postal_code": "629011400",
            "telephone_number": "618-536-6621"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "611 W Main St",
            "address_purpose": "LOCATION",
            "city": "Fredericktown",
            "state": "MO",
            "postal_code": "636451146",
            "country_code": "US",
            "telephone_number": "573-783-3341",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "MCKIBBEN",
        "first_name": "TYLER",
        "middle_name": "PATRICK",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2025-01-16",
        "last_updated": "2025-07-08",
        "certification_date": "2025-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "MO",
            "license": null,
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "MO",
            "license": "2025005124",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "IL",
            "license": "125086259",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MD",
            "identifier": "125086259",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ASSISTANT PHYSICIAN MO LICENSE",
            "identifier": "2025005124",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Shauna Lee Thomason McGuire, PHARMD
• Whitney McGuire, NP
• Mandy Jo McKee, LCSW
• Marissa McKee, MRC, CRC, LPC, CRADC
• Zachary H McKenty, PHYSICIAN ASSISTANT
• Deedra Gail McLain, M.D.
• Jonnah Shayne McManus, MD
• Alyssa Dawn McMillen
• Andrew McNally, CRNA
• Gage McPhail, BA

• Family Medicine Physician in Carbondale, IL
• Providers in Carbondale, IL by specialty
• Family Medicine Physician in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.