Provider Demographics
NPI:1982741328
Name:GILLISS, ADAM C (DO)
Entity Type:Individual
Prefix:DR
First Name:ADAM
Middle Name:C
Last Name:GILLISS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:ADAM
Other - Middle Name:C
Other - Last Name:GILLISS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:27 E CHESTNUT AVE
Mailing Address - Street 2:
Mailing Address - City:MERCHANTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08109-2504
Mailing Address - Country:US
Mailing Address - Phone:856-662-0424
Mailing Address - Fax:856-662-7404
Practice Address - Street 1:27 E CHESTNUT AVE
Practice Address - Street 2:
Practice Address - City:MERCHANTVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08109-2504
Practice Address - Country:US
Practice Address - Phone:856-662-0424
Practice Address - Fax:856-662-7404
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB59981207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJG02300Medicare UPIN