MEDICARE: SAMUEL THOMAS GILLILAND IDC

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	1710I1002X	Independent Duty Corpsman

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1710I1002X	OTHER		INDEPENDENT DUTY CORPSMAN

General Provider Information

NPI Number	:	1679540645
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL THOMAS GILLILAND IDC

Provider Business Mailing Address
First Line	:	NAVAL HOSPITAL JACKSONVILLE
Second Line	:	2080 CHILD ST
City	:	JACKSONVILLE
State	:	FL
Zip	:	32214-5000
Country	:	US
Telephone Number	:	904-542-3500
Fax Number	:

Provider Business Practice Location Address
First Line	:	NAVAL HOSPITAL JACKSONVILLE
Second Line	:	2080 CHILD ST
City	:	JACKSONVILLE
State	:	FL
Zip	:	32214-5000
Country	:	US
Telephone Number	:	904-542-3500
Fax Number	:

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

Provider Enumeration Date	:	03/08/2006
Last Update Date	:	07/30/2012

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