1699836593 NPI number — MR. LEROY E GILLAN CRNA

Table of content: MR. LEROY E GILLAN CRNA (NPI 1699836593)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699836593 NPI number — MR. LEROY E GILLAN CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GILLAN
Provider First Name:
LEROY
Provider Middle Name:
E
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CRNA
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:
1699836593
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1600 CENTRAL DR
Provider Second Line Business Mailing Address:
SUITE 160
Provider Business Mailing Address City Name:
BEDFORD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76022-6000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-268-0104
Provider Business Mailing Address Fax Number:
817-268-6102

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 CENTRAL DR
Provider Second Line Business Practice Location Address:
SUITE 160
Provider Business Practice Location Address City Name:
BEDFORD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76022-6000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-268-0104
Provider Business Practice Location Address Fax Number:
817-268-6102
Provider Enumeration Date:
12/13/2006

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: 367500000X , with the licence number:  010720 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 037214601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 180403400 . This is a "DEPT OF LABOR KENTUCKY" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 430042809 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: CRNA10720 . This is a "TEXAS WC" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 81179U . This is a "BLUE SHIELD OF TEXAS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 006895499 . This is a "EEOICP WC" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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