Provider Demographics
NPI:1245230275
Name:GILLIAM-PHILLIPS, RUTH LATANYA (DPM)
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:LATANYA
Last Name:GILLIAM-PHILLIPS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:RUTH
Other - Middle Name:LATANYA
Other - Last Name:GILLIAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPM
Mailing Address - Street 1:7575 RITCHIE HWY
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-8951
Mailing Address - Country:US
Mailing Address - Phone:410-766-1444
Mailing Address - Fax:410-766-9453
Practice Address - Street 1:7575 RITCHIE HWY
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-8951
Practice Address - Country:US
Practice Address - Phone:410-766-1444
Practice Address - Fax:410-766-9453
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01250213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD54686502OtherBSMD
MD54686502OtherBSMD
U64674Medicare UPIN