Provider Demographics
NPI:1669225629
Name:GILMORE, SAMUEL JACOB
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:JACOB
Last Name:GILMORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 HENDERSON LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH BLOOMFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:43103-8500
Mailing Address - Country:US
Mailing Address - Phone:614-974-4248
Mailing Address - Fax:
Practice Address - Street 1:59 HENDERSON LN
Practice Address - Street 2:
Practice Address - City:SOUTH BLOOMFIELD
Practice Address - State:OH
Practice Address - Zip Code:43103-8500
Practice Address - Country:US
Practice Address - Phone:614-974-4248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-09
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker