Provider Demographics
NPI:1356567358
Name:GILLIS, BENJAMIN DAVID (DC)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:DAVID
Last Name:GILLIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5675 BURLINGAME AVE.
Mailing Address - Street 2:SUITE A
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49509-9702
Mailing Address - Country:US
Mailing Address - Phone:616-538-2200
Mailing Address - Fax:616-301-0419
Practice Address - Street 1:5675 BURLINGAME AVE.
Practice Address - Street 2:SUITE A
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509-9702
Practice Address - Country:US
Practice Address - Phone:616-538-2200
Practice Address - Fax:616-301-0419
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008777111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950D113070OtherBLUE CROSS BLUE SHIELD
MION84880OtherMEDICARE PTAN
MIU98445Medicare UPIN