Provider Demographics
NPI:1063426005
Name:GILLILAND, MICHAEL WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WILLIAM
Last Name:GILLILAND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1498 SE TECH CENTER PL
Mailing Address - Street 2:SUITE 340
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9591
Mailing Address - Country:US
Mailing Address - Phone:360-260-0235
Mailing Address - Fax:
Practice Address - Street 1:1322 3RD ST SE
Practice Address - Street 2:SUITE 100
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3771
Practice Address - Country:US
Practice Address - Phone:253-697-4128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00042973207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA20202185198372A002OtherTRICARE ID
WA1322GIOtherREGENCE BLUE SHIELD ID
WA1119296Medicaid
WAP00257376OtherRAILROAD MEDICARE ID
WAH66177Medicare UPIN
WA1119296Medicaid