Provider Demographics
NPI:1790773091
Name:GILLUM, JEFFREY (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:GILLUM
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 1:43800 GARFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1136
Mailing Address - Country:US
Mailing Address - Phone:800-848-0202
Mailing Address - Fax:586-226-6949
Practice Address - Street 1:4727 SAINT ANTOINE ST
Practice Address - Street 2:SUITE 210
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-1461
Practice Address - Country:US
Practice Address - Phone:313-831-3066
Practice Address - Fax:313-831-8438
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301041555207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5215491Medicaid
MI4502243Medicaid
MI5188750Medicaid
MIM71670163Medicare PIN
MIP35120157Medicare PIN
N71840003Medicare ID - Type Unspecified
MI5188750Medicaid