Provider Demographics
NPI:1083602965
Name:PAYNE, GILLIS L JR (MD)
Entity Type:Individual
Prefix:
First Name:GILLIS
Middle Name:L
Last Name:PAYNE
Suffix:JR
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 1:10036 WOODLEY RD
Mailing Address - Street 2:
Mailing Address - City:RAMER
Mailing Address - State:AL
Mailing Address - Zip Code:36069-6531
Mailing Address - Country:US
Mailing Address - Phone:334-281-7578
Mailing Address - Fax:
Practice Address - Street 1:7006 FULTON CT
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-8022
Practice Address - Country:US
Practice Address - Phone:334-244-7209
Practice Address - Fax:334-244-6604
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5281208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000004903Medicaid
AL51004903OtherBCBS PROVIDER NUMBER
AL000004903Medicaid