Provider Demographics
NPI:1033262753
Name:KILGO, GARY RODERICK (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:RODERICK
Last Name:KILGO
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 1:527 MAIN AVENUE
Mailing Address - Street 2:SUITE E
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35476-0467
Mailing Address - Country:US
Mailing Address - Phone:205-349-2223
Mailing Address - Fax:205-349-2310
Practice Address - Street 1:527 MAIN AVENUE
Practice Address - Street 2:SUITE E
Practice Address - City:NORTHPORT
Practice Address - State:AL
Practice Address - Zip Code:35476-0467
Practice Address - Country:US
Practice Address - Phone:205-349-2223
Practice Address - Fax:205-349-2310
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL95292084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALC74466Medicare UPIN