Provider Demographics
NPI:1033121751
Name:JEAN GILLES, FRITZ E (MD)
Entity Type:Individual
Prefix:
First Name:FRITZ E
Middle Name:
Last Name:JEAN GILLES
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:PO BOX 402145
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-2145
Mailing Address - Country:US
Mailing Address - Phone:803-296-7303
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:129 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-4949
Practice Address - Country:US
Practice Address - Phone:803-774-9680
Practice Address - Fax:803-774-5217
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96553207R00000X
NY241858207R00000X
SC35366207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC353664Medicaid
NYA400001522Medicare PIN
SC353664Medicaid