Provider Demographics
NPI:1639467913
Name:RICHARD S GILLUM INC PC
Entity Type:Organization
Organization Name:RICHARD S GILLUM INC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:D
Authorized Official - Last Name:GILLUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-888-7576
Mailing Address - Street 1:1259 N STATE ROAD 135
Mailing Address - Street 2:SUITE E
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-1033
Mailing Address - Country:US
Mailing Address - Phone:317-888-7576
Mailing Address - Fax:317-888-0047
Practice Address - Street 1:1259 N STATE ROAD 135
Practice Address - Street 2:SUITE E
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-1033
Practice Address - Country:US
Practice Address - Phone:317-888-7576
Practice Address - Fax:317-888-0047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-20
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008573122300000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN6613800001Medicare NSC