Provider Demographics
NPI:1215411624
Name:LEAH B. GILLIAM, MD.
Entity Type:Organization
Organization Name:LEAH B. GILLIAM, MD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LEAH
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLIAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:731-614-7957
Mailing Address - Street 1:83 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38351-2109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:83 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:TN
Practice Address - Zip Code:38351-2109
Practice Address - Country:US
Practice Address - Phone:731-614-7957
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-20
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN=========OtherTAX ID