Provider Demographics
NPI:1396735437
Name:SCHILLHAMMER, GARY LEE (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:LEE
Last Name:SCHILLHAMMER
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:PO BOX 309
Mailing Address - Street 2:
Mailing Address - City:DARRINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98241-0309
Mailing Address - Country:US
Mailing Address - Phone:360-436-1055
Mailing Address - Fax:360-436-0146
Practice Address - Street 1:1190 RIDDLE ST
Practice Address - Street 2:
Practice Address - City:DARRINGTON
Practice Address - State:WA
Practice Address - Zip Code:98241
Practice Address - Country:US
Practice Address - Phone:360-436-1055
Practice Address - Fax:360-436-0146
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00021477207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7108020Medicaid
508509Medicare Oscar/Certification
A09189Medicare UPIN
WA7108020Medicaid