Provider Demographics
NPI:1043223662
Name:KILLEN, GARY
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:KILLEN
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 1:27 OAKFIELD DR SE
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-5932
Mailing Address - Country:US
Mailing Address - Phone:706-234-9301
Mailing Address - Fax:
Practice Address - Street 1:27 OAKFIELD DR SE
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-5932
Practice Address - Country:US
Practice Address - Phone:706-234-9301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048161208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
A98563Medicare UPIN
GA202I112745Medicare PIN