Provider Demographics
NPI:1801209143
Name:GILLES, MICHAEL
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:GILLES
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 1:3170 KETTERING BLVD BLDG B3
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3186
Mailing Address - Fax:
Practice Address - Street 1:30 E APPLE ST STE NW3300
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2939
Practice Address - Country:US
Practice Address - Phone:937-208-8394
Practice Address - Fax:937-208-8388
Is Sole Proprietor?:No
Enumeration Date:2014-06-04
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.352635163WP0000X
OHAPRN.CNS.15989364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology
No163WP0000XNursing Service ProvidersRegistered NursePain Management