Provider Demographics
NPI:1245488964
Name:JAI H.GILLIAM, M.D. , PLLC
Entity type:Organization
Organization Name:JAI H.GILLIAM, M.D. , PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JAI
Authorized Official - Middle Name:HERMAN
Authorized Official - Last Name:GILLIAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-294-0077
Mailing Address - Street 1:1782 BRYAN STATION RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40505-2133
Mailing Address - Country:US
Mailing Address - Phone:859-294-0077
Mailing Address - Fax:859-294-0078
Practice Address - Street 1:1782 BRYAN STATION RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40505-2133
Practice Address - Country:US
Practice Address - Phone:859-294-0077
Practice Address - Fax:859-294-0078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-05
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39604261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64111156Medicaid
KY0978906Medicare PIN
KYI43386Medicare UPIN