Provider Demographics
NPI:1407933583
Name:GILLUM, CHARLES L (AUD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:L
Last Name:GILLUM
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1213 HYLTON HEIGHTS RD
Mailing Address - Street 2:SUTIE 105
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502-2810
Mailing Address - Country:US
Mailing Address - Phone:785-537-4005
Mailing Address - Fax:
Practice Address - Street 1:1213 HYLTON HEIGHTS RD
Practice Address - Street 2:SUTIE 105
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-2810
Practice Address - Country:US
Practice Address - Phone:785-537-4005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS368231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS115310Medicare ID - Type Unspecified