Provider Demographics
NPI:1962601369
Name:DR GARY L GILLEN
Entity type:Organization
Organization Name:DR GARY L GILLEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GILLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:740-420-9288
Mailing Address - Street 1:PO BOX 39
Mailing Address - Street 2:131 LEWIS AVE
Mailing Address - City:CIRCLEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43113
Mailing Address - Country:US
Mailing Address - Phone:740-420-9288
Mailing Address - Fax:740-420-3070
Practice Address - Street 1:131 LEWIS AVE
Practice Address - Street 2:
Practice Address - City:CIRCLEVILLE
Practice Address - State:OH
Practice Address - Zip Code:43113
Practice Address - Country:US
Practice Address - Phone:740-420-9288
Practice Address - Fax:740-420-3070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-16
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHGA9339531OtherMEDICARE