Provider Demographics
NPI:1568654887
Name:GARY L GILCREASE MD, PA
Entity Type:Organization
Organization Name:GARY L GILCREASE MD, PA
Other - Org Name:GILCREASE MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD, PRESIDENT, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:GILCREASE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PA
Authorized Official - Phone:512-268-2091
Mailing Address - Street 1:135 BUNTON CREEK RD STE 102
Mailing Address - Street 2:
Mailing Address - City:KYLE
Mailing Address - State:TX
Mailing Address - Zip Code:78640-5701
Mailing Address - Country:US
Mailing Address - Phone:512-268-2091
Mailing Address - Fax:512-268-2190
Practice Address - Street 1:135 BUNTON CREEK RD STE 102
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-5701
Practice Address - Country:US
Practice Address - Phone:512-268-2091
Practice Address - Fax:512-268-2190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-10
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9069207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144784901Medicaid
TXK9069OtherMEDICAL LICENSE
TX00169VMedicare PIN
TXK9069OtherMEDICAL LICENSE