Provider Demographics
NPI:1790104701
Name:GILLIS, ELEANOR
Entity Type:Individual
Prefix:
First Name:ELEANOR
Middle Name:
Last Name:GILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:491 ALLENDALE RD STE 104
Mailing Address - Street 2:
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-1430
Mailing Address - Country:US
Mailing Address - Phone:267-785-2897
Mailing Address - Fax:
Practice Address - Street 1:777 TOWNSHIP LINE RD STE 150
Practice Address - Street 2:
Practice Address - City:YARDLEY
Practice Address - State:PA
Practice Address - Zip Code:19067-5567
Practice Address - Country:US
Practice Address - Phone:215-860-3360
Practice Address - Fax:215-860-3362
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-08
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA109122002085N0904X, 2085R0202X
PAMD4623312085N0904X, 2085R0202X
MA2780932085R0202X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program