Provider Demographics
NPI:1891003802
Name:SHANE GILLIAM, M.D., P.A.
Entity Type:Organization
Organization Name:SHANE GILLIAM, M.D., P.A.
Other - Org Name:FAMILY MEDICINE ASSOCIATES OF STEPHENVILLE
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:SHANE
Authorized Official - Last Name:GILLIAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:254-965-8760
Mailing Address - Street 1:630 N GRAHAM STREET
Mailing Address - Street 2:
Mailing Address - City:STEPHENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76401-3552
Mailing Address - Country:US
Mailing Address - Phone:254-965-8760
Mailing Address - Fax:254-965-8766
Practice Address - Street 1:630 N GRAHAM STREET
Practice Address - Street 2:
Practice Address - City:STEPHENVILLE
Practice Address - State:TX
Practice Address - Zip Code:76401-3552
Practice Address - Country:US
Practice Address - Phone:254-965-8760
Practice Address - Fax:254-965-8766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-24
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7278261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care