Provider Demographics
NPI:1043845787
Name:GILLIAM, BLAKE HAMILTON
Entity Type:Individual
Prefix:MR
First Name:BLAKE
Middle Name:HAMILTON
Last Name:GILLIAM
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 1:1230 SLAUGHTER RD STE C
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-5901
Mailing Address - Country:US
Mailing Address - Phone:256-325-0955
Mailing Address - Fax:
Practice Address - Street 1:1230 SLAUGHTER RD STE C
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-5901
Practice Address - Country:US
Practice Address - Phone:256-325-0955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-03
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-153719363LG0600X, 363L00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care