Provider Demographics
NPI:1396725057
Name:GILLIS, THERESA A (MD)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:A
Last Name:GILLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 MADISON AVE FRNT 5
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-5488
Mailing Address - Country:US
Mailing Address - Phone:646-888-1936
Mailing Address - Fax:646-888-1910
Practice Address - Street 1:515 MADISON AVE FRNT 5
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-5488
Practice Address - Country:US
Practice Address - Phone:646-888-1936
Practice Address - Fax:646-888-1910
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA10013000208100000X, 2081H0002X, 2081P2900X
NY824091972081H0002X, 2081P2900X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081H0002XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationHospice and Palliative Medicine
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEF63745Medicare UPIN
DE013170C35Medicare PIN