Provider Demographics
NPI:1285655795
Name:GILLHAM, GREG A (MD)
Entity type:Individual
Prefix:
First Name:GREG
Middle Name:A
Last Name:GILLHAM
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 1:555 S 70TH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68510-2462
Mailing Address - Country:US
Mailing Address - Phone:402-421-0904
Mailing Address - Fax:402-421-0946
Practice Address - Street 1:555 S 70TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68510-2462
Practice Address - Country:US
Practice Address - Phone:402-219-8747
Practice Address - Fax:402-219-8748
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE19515207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
2663OtherMIDLANDS CHOICE
KS100380010AMedicaid
IA2959239Medicaid
NE76-00113OtherUHC
NE03636OtherBCBS
NE470780857 23Medicaid
2663OtherMIDLANDS CHOICE
NE03636OtherBCBS
IA2959239Medicaid