Provider Demographics
NPI:1609849868
Name:GILLY, PHILIP ALAIN (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:ALAIN
Last Name:GILLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6773 W MAPLE RD
Mailing Address - Street 2:HENRY FORD MAPLEGROVE CENTER
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3013
Mailing Address - Country:US
Mailing Address - Phone:248-661-6100
Mailing Address - Fax:
Practice Address - Street 1:8623 N WAYNE RD STE 104
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-1137
Practice Address - Country:US
Practice Address - Phone:734-469-2770
Practice Address - Fax:734-793-5312
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY180754207Q00000X
MI4301098753207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01166201Medicaid
34F971Medicare ID - Type Unspecified
NY01166201Medicaid