Provider Demographics
NPI:1972079473
Name:GILLMAN, TRENT
Entity type:Individual
Prefix:MR
First Name:TRENT
Middle Name:
Last Name:GILLMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1198 STATE ROAD 46 E
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47006-9232
Mailing Address - Country:US
Mailing Address - Phone:855-600-6251
Mailing Address - Fax:855-600-6386
Practice Address - Street 1:1198 STATE ROAD 46 E
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:IN
Practice Address - Zip Code:47006-9232
Practice Address - Country:US
Practice Address - Phone:855-600-6251
Practice Address - Fax:855-600-6386
Is Sole Proprietor?:No
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100295890AMedicaid