Provider Demographics
NPI:1881730042
Name:DR. BRIAN GILLIS P C
Entity type:Organization
Organization Name:DR. BRIAN GILLIS P C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:GILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:478-987-9666
Mailing Address - Street 1:PO BOX 628
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:GA
Mailing Address - Zip Code:31069-0628
Mailing Address - Country:US
Mailing Address - Phone:478-987-9666
Mailing Address - Fax:478-988-8091
Practice Address - Street 1:1207 HOUSTON LAKE DR STE C
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:GA
Practice Address - Zip Code:31069-3590
Practice Address - Country:US
Practice Address - Phone:478-987-9666
Practice Address - Fax:478-988-8091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIRO05526111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000806616AMedicaid
GADH0819OtherRAILROAD MEDICARE
GA511G700130Medicare PIN