Provider Demographics
NPI:1386711877
Name:GILLIS, BRIAN (DO)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:GILLIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 WATER ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04963-4956
Mailing Address - Country:US
Mailing Address - Phone:207-465-3003
Mailing Address - Fax:207-465-7352
Practice Address - Street 1:8 WATER ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:ME
Practice Address - Zip Code:04963-4956
Practice Address - Country:US
Practice Address - Phone:207-465-3003
Practice Address - Fax:207-465-7352
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2008-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1513208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
2274735OtherAETNA
M177120OtherCIGNA
ME038507OtherANTHEM
ME154490099Medicaid
H00479OtherHARVARD PILGRIM HEALTHCAR
2274735OtherAETNA
ME154490099Medicaid
ME100013931Medicare PIN