Provider Demographics
NPI:1629394705
Name:MERRI BETH GILLIAM CRNP, PC
Entity Type:Organization
Organization Name:MERRI BETH GILLIAM CRNP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CRNP / OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MERRI
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:GILLIAM
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:256-233-0712
Mailing Address - Street 1:PO BOX 1735
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:AL
Mailing Address - Zip Code:35612-6735
Mailing Address - Country:US
Mailing Address - Phone:256-233-0712
Mailing Address - Fax:256-233-3535
Practice Address - Street 1:707 US HIGHWAY 31 S
Practice Address - Street 2:SUITE D
Practice Address - City:ATHENS
Practice Address - State:AL
Practice Address - Zip Code:35611-3619
Practice Address - Country:US
Practice Address - Phone:256-233-0712
Practice Address - Fax:256-233-3535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-14
Last Update Date:2010-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-073255208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL891017564Medicaid