Provider Demographics
NPI:1528302874
Name:GILL, MARY SUSAN
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:SUSAN
Last Name:GILL
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 1:209 WINDWARD AVE
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08722-3941
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:830 BEAR TAVERN RD
Practice Address - Street 2:
Practice Address - City:EWING
Practice Address - State:NJ
Practice Address - Zip Code:08628-1020
Practice Address - Country:US
Practice Address - Phone:800-370-3651
Practice Address - Fax:860-510-0020
Is Sole Proprietor?:No
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NC06872900363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner