Provider Demographics
NPI:1750775037
Name:KELLEY A. GILLROY-GILL
Entity type:Organization
Organization Name:KELLEY A. GILLROY-GILL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GILLROY-GILL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:623-238-4022
Mailing Address - Street 1:165 LILLY RD NE STE A
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5086
Mailing Address - Country:US
Mailing Address - Phone:360-438-9092
Mailing Address - Fax:360-438-3906
Practice Address - Street 1:165 LILLY RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5086
Practice Address - Country:US
Practice Address - Phone:360-438-9092
Practice Address - Fax:360-438-3906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-24
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO 60507941213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7392670001OtherPTAN
WAG8941881Medicare UPIN