Provider Demographics
NPI: | 1760550602 |
---|---|
Name: | GILLIAM, MICHAEL C (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | MICHAEL |
Middle Name: | C |
Last Name: | GILLIAM |
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: | PO BOX 19305 |
Mailing Address - Street 2: | |
Mailing Address - City: | CHARLOTTE |
Mailing Address - State: | NC |
Mailing Address - Zip Code: | 28219-9305 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 500 LAUCHWOOD DR |
Practice Address - Street 2: | |
Practice Address - City: | LAURINBURG |
Practice Address - State: | NC |
Practice Address - Zip Code: | 28352-5501 |
Practice Address - Country: | US |
Practice Address - Phone: | 910-291-6904 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-11-30 |
Last Update Date: | 2023-12-18 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NC | 2008-01235 | 208M00000X, 207R00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | |
No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NC | 1760550602 | Medicaid | |
NC | 5909894 | Medicaid | |
SC | NC1314 | Medicaid | |
NC | 2022602 | Medicare PIN | |
SC | NC1314 | Medicaid | |
NC | NCK054A | Medicare PIN | |
NC | NCK054E310 | Medicare PIN |