Provider Demographics
NPI:1881696136
Name:GILLEN, JOHN A II (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:A
Last Name:GILLEN
Suffix:II
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 1:900 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GRANDVIEW
Mailing Address - State:MO
Mailing Address - Zip Code:64030-2477
Mailing Address - Country:US
Mailing Address - Phone:816-331-6700
Mailing Address - Fax:816-876-2399
Practice Address - Street 1:900 MAIN ST
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:MO
Practice Address - Zip Code:64030-2477
Practice Address - Country:US
Practice Address - Phone:816-331-6700
Practice Address - Fax:816-876-2399
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO110898207X00000X
KS30353207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208537613Medicaid
MO23296023OtherBCBS INDIVIDUAL #
MO607374400OtherDEPT OF LABOR
KS208537621Medicaid
MO208537639Medicaid
MO17519026OtherBCBS GROUP #
MO17519026OtherBCBS GROUP #
MOR500000AMedicare ID - Type UnspecifiedGROUP # CASS COUNTY
MOF46097Medicare UPIN
MOP00178155Medicare ID - Type UnspecifiedRAILROAD MEDICARE INDIVID
KS208537621Medicaid
KSR509400BMedicare ID - Type UnspecifiedINDIVIDUAL # JOHNSON CNTY
MODC5878Medicare ID - Type UnspecifiedRAILROAD MEDICARE GROUP #
MO208537613Medicaid
MO208537639Medicaid