MEDICARE: DR. BRUCE S GILLIS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	G30367	CA

General Provider Information

NPI Number	:	1013945542
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRUCE S GILLIS M.D.

Provider Business Mailing Address
First Line	:	11801 W OLYMPIC BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-1114
Country	:	US
Telephone Number	:	310-268-1001
Fax Number	:	310-268-1015

Provider Business Practice Location Address
First Line	:	11801 W OLYMPIC BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-1114
Country	:	US
Telephone Number	:	310-268-1001
Fax Number	:	310-268-1015

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2006
Last Update Date	:	02/06/2019

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