Provider Demographics
NPI:1023016912
Name:GILLIAM, GEORGE STEPHEN (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:STEPHEN
Last Name:GILLIAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 E PARRISH AVE
Mailing Address - Street 2:BLDG B, STE 203
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-1449
Mailing Address - Country:US
Mailing Address - Phone:270-691-9697
Mailing Address - Fax:270-691-0485
Practice Address - Street 1:2200 E PARRISH AVE
Practice Address - Street 2:BLDG B, STE 203
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-1449
Practice Address - Country:US
Practice Address - Phone:270-691-9697
Practice Address - Fax:270-691-0485
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22817174400000X
KY41068208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100329260BMedicaid
KY64228174Medicaid
KY000000051542OtherBS OF KY
KY611303681OtherCOMMERCIAL INSURANCE
KY0681501Medicare ID - Type Unspecified
KY000000051542OtherBS OF KY
KY64228174Medicaid
KY020032741Medicare ID - Type UnspecifiedRAILROAD
IN100329260BMedicaid