Provider Demographics
NPI:1063521243
Name:GILL, MARVIN GARY (MED)
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:GARY
Last Name:GILL
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 CEDAR GROVE LOOP
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:TN
Mailing Address - Zip Code:38008-9815
Mailing Address - Country:US
Mailing Address - Phone:731-658-6113
Mailing Address - Fax:731-658-6165
Practice Address - Street 1:10710 OLD HIGHWAY 64
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:TN
Practice Address - Zip Code:38008-3587
Practice Address - Country:US
Practice Address - Phone:731-658-6113
Practice Address - Fax:731-658-6165
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor