Provider Demographics
NPI:1427096221
Name:GILLEN, PATRICIA
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:GILLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1106 ANNAPOLIS RD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-1637
Mailing Address - Country:US
Mailing Address - Phone:410-874-1400
Mailing Address - Fax:
Practice Address - Street 1:1106 ANNAPOLIS RD
Practice Address - Street 2:SUITE 310
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113-1637
Practice Address - Country:US
Practice Address - Phone:410-874-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD43220207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD761331800Medicaid
MDF12152Medicare UPIN
MD584L952CMedicare PIN
141683GZ9Medicare PIN
MD761331800Medicaid