Provider Demographics
NPI:1982331930
Name:GILL, RICHARD J (PTA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:GILL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 E HILL RD STE H
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-5425
Mailing Address - Country:US
Mailing Address - Phone:810-606-8766
Mailing Address - Fax:810-606-8770
Practice Address - Street 1:2240 E HILL RD STE H
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-5425
Practice Address - Country:US
Practice Address - Phone:810-606-8766
Practice Address - Fax:810-606-8770
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-01
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502004016225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5502004016OtherSTATE OF MICHIGAN