Provider Demographics
NPI:1114030137
Name:CIRILLI, GARY A
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:A
Last Name:CIRILLI
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 1:113 W JACKSON ST STE B
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-2402
Mailing Address - Country:US
Mailing Address - Phone:601-354-4327
Mailing Address - Fax:601-360-0822
Practice Address - Street 1:113 W JACKSON ST STE B
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-2402
Practice Address - Country:US
Practice Address - Phone:601-354-4327
Practice Address - Fax:601-360-0822
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11708174400000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0115574Medicaid
MSPTAN3021300402Medicare PIN
MSE14248Medicare UPIN
MS0115574Medicaid