Provider Demographics
NPI:1225198120
Name:GILLIM, STUART WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:STUART
Middle Name:WILLIAM
Last Name:GILLIM
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 1:1969 TIMMERMAN HILL RD.
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045
Mailing Address - Country:US
Mailing Address - Phone:607-835-6570
Mailing Address - Fax:
Practice Address - Street 1:1969 TIMMERMAN HILL RD.
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045
Practice Address - Country:US
Practice Address - Phone:607-835-6570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY108764207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00363084Medicaid
NY00363084Medicaid
53222BMedicare ID - Type Unspecified