Provider Demographics
NPI:1386636165
Name:P. GILL OBSTETRICS & GYNECOLOGY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:P. GILL OBSTETRICS & GYNECOLOGY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO-CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:PARAM
Authorized Official - Middle Name:K
Authorized Official - Last Name:GILL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-465-5550
Mailing Address - Street 1:PO BOX 1090
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95241-1090
Mailing Address - Country:US
Mailing Address - Phone:209-465-5550
Mailing Address - Fax:209-334-0127
Practice Address - Street 1:999 S FAIRMONT AVE
Practice Address - Street 2:STE 230
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5100
Practice Address - Country:US
Practice Address - Phone:209-465-5550
Practice Address - Fax:209-334-0127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-18
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0081080Medicaid
CAZZZ14503ZMedicare ID - Type Unspecified