Provider Demographics
NPI:1164432308
Name:GILLIAM, ROBERT LEE (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:LEE
Last Name:GILLIAM
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 1:1414 ELBA HWY
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:AL
Mailing Address - Zip Code:36079-6020
Mailing Address - Country:US
Mailing Address - Phone:334-670-6726
Mailing Address - Fax:334-670-6731
Practice Address - Street 1:1412 ELBA HWY
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:AL
Practice Address - Zip Code:36079-6020
Practice Address - Country:US
Practice Address - Phone:334-566-8822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL15599207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051046137OtherBCBS
AL631802004Medicaid
AL631802004Medicaid
AL000083112Medicare ID - Type Unspecified