1275795700 NPI number — PHILIP JOSEPH RAYMUND GILLEN MD

Table of content: KRISTIN DANG PHARMD (NPI 1962937904)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275795700 NPI number — PHILIP JOSEPH RAYMUND GILLEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GILLEN
Provider First Name:
PHILIP
Provider Middle Name:
JOSEPH RAYMUND
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275795700
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3621 S STATE ST
Provider Second Line Business Mailing Address:
700 KMS PLACE
Provider Business Mailing Address City Name:
ANN ARBOR
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-936-2047
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 EAST MEDICAL CENTER DR
Provider Second Line Business Practice Location Address:
2ND FLOOR TAUBMAN CTR RECP G
Provider Business Practice Location Address City Name:
ANN ARBOR
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48109-5222
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-763-5828
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/26/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  4301091490 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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