Provider Demographics
NPI:1700881836
Name:GILL, THOMAS W (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:W
Last Name:GILL
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 1:301 MED TECH PKWY
Mailing Address - Street 2:STE 160
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2364
Mailing Address - Country:US
Mailing Address - Phone:423-794-5560
Mailing Address - Fax:423-975-0051
Practice Address - Street 1:301 MED TECH PKWY
Practice Address - Street 2:STE 160
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2364
Practice Address - Country:US
Practice Address - Phone:423-794-5560
Practice Address - Fax:423-975-0051
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN24114208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3080863Medicaid
TNF08639Medicare UPIN
TN3080868Medicare PIN