1891704474 NPI number — FRANCIS ROOSEVELT GILLIAM III MD

Table of content: FRANCIS ROOSEVELT GILLIAM III MD (NPI 1891704474)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891704474 NPI number — FRANCIS ROOSEVELT GILLIAM III MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GILLIAM
Provider First Name:
FRANCIS
Provider Middle Name:
ROOSEVELT
Provider Name Prefix Text:
Provider Name Suffix Text:
III
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:
GILLIAM
Provider Other First Name:
ROSEY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
III
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1891704474
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 743904
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30374-3904
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-296-7320
Provider Business Mailing Address Fax Number:
803-296-7330

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 N SUMTER ST STE 410
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUMTER
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-774-9797
Provider Business Practice Location Address Fax Number:
803-774-9796
Provider Enumeration Date:
08/05/2006

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: 207RC0000X , with the licence number:  14615 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0001X , with the licence number: 14615 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8935558 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 14615 . This is a "STATE LICENSE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 27190 . This is a "STATE LICENSE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 0101043514 . This is a "STATE LICENSE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: Q27190 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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