Provider Demographics
NPI:1164617866
Name:GILLES, THOMAS FREDERICK (MD,)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:FREDERICK
Last Name:GILLES
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 1:300 PARK ST S
Mailing Address - Street 2:P.O. BOX 529
Mailing Address - City:FAIRFAX
Mailing Address - State:MN
Mailing Address - Zip Code:55332-3153
Mailing Address - Country:US
Mailing Address - Phone:507-426-7228
Mailing Address - Fax:
Practice Address - Street 1:300 PARK ST S
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:MN
Practice Address - Zip Code:55332-3153
Practice Address - Country:US
Practice Address - Phone:507-426-7228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-06
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN18493207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MND75618Medicare UPIN
MN0109000286Medicare PIN