Provider Demographics
NPI:1497957419
Name:GILL MEMORIAL ENT CLINIC, PC
Entity Type:Organization
Organization Name:GILL MEMORIAL ENT CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:HANABURY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:540-344-2071
Mailing Address - Street 1:707 S JEFFERSON ST FL 5
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016-5100
Mailing Address - Country:US
Mailing Address - Phone:540-344-2071
Mailing Address - Fax:540-982-8490
Practice Address - Street 1:707 S JEFFERSON ST FL 5
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-5100
Practice Address - Country:US
Practice Address - Phone:540-344-2071
Practice Address - Fax:540-982-8490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101031266174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4243474OtherAETNA
VA143175OtherANTHEM
VA243144OtherSOUTHERN HEALTH
VAP00143294OtherRAILROAD MEDICARE
VA143175OtherANTHEM
VAB07330Medicare UPIN