Provider Demographics
NPI:1558404343
Name:GILLIAM, JAI H (MD)
Entity Type:Individual
Prefix:DR
First Name:JAI
Middle Name:H
Last Name:GILLIAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 910670
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40591-0670
Mailing Address - Country:US
Mailing Address - Phone:859-971-4685
Mailing Address - Fax:859-971-4602
Practice Address - Street 1:100 PROVIDENCE WAY
Practice Address - Street 2:SUITE 200
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-6031
Practice Address - Country:US
Practice Address - Phone:859-260-5370
Practice Address - Fax:859-260-5379
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39604208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64111156Medicaid
KYK080650Medicare PIN