Provider Demographics
NPI:1265630297
Name:ROY H. GILLICK
Entity Type:Organization
Organization Name:ROY H. GILLICK
Other - Org Name:GRAND PARK MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:M.D./OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:H
Authorized Official - Last Name:GILLICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-392-2222
Mailing Address - Street 1:830 MASON RD
Mailing Address - Street 2:#A4
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77450-3896
Mailing Address - Country:US
Mailing Address - Phone:281-392-2222
Mailing Address - Fax:
Practice Address - Street 1:830 MASON RD
Practice Address - Street 2:#A4
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77450-3896
Practice Address - Country:US
Practice Address - Phone:281-392-2222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-11
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE7950261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00ES02Medicare PIN
TXB22984Medicare UPIN