Provider Demographics
NPI:1952620460
Name:GILLHAM, MARIEL (M D)
Entity Type:Individual
Prefix:
First Name:MARIEL
Middle Name:
Last Name:GILLHAM
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-8710
Mailing Address - Country:US
Mailing Address - Phone:910-715-2164
Mailing Address - Fax:910-715-4493
Practice Address - Street 1:1400 E BOULDER ST STE 2508
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5533
Practice Address - Country:US
Practice Address - Phone:719-365-1292
Practice Address - Fax:719-365-6997
Is Sole Proprietor?:No
Enumeration Date:2010-05-24
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0071609207R00000X
NC01382208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC18034OtherBCBS
NC1952620460Medicaid
NC18034OtherBCBS