Provider Demographics
NPI:1538125596
Name:GILMORE, KATHLEEN MARY (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:MARY
Last Name:GILMORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:MARY
Other - Last Name:MATTIC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:315 E EISENHOWER PKWY STE 8
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-3329
Mailing Address - Country:US
Mailing Address - Phone:734-794-3786
Mailing Address - Fax:734-794-3788
Practice Address - Street 1:315 E EISENHOWER PKWY STE 8
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-3329
Practice Address - Country:US
Practice Address - Phone:734-794-3786
Practice Address - Fax:734-794-3788
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301065592207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104830736Medicaid
MIH69286Medicare UPIN