MEDICARE: BRENT W GILLUM D O PLC

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	207V00000X	Obstetrics & Gynecology Physician	007845	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710926670
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRENT W GILLUM D O PLC

Provider Business Mailing Address
First Line	:	4727 SAINT ANTOINE ST
Second Line	:	SUITE 210
City	:	DETROIT
State	:	MI
Zip	:	48201-1461
Country	:	US
Telephone Number	:	313-831-3066
Fax Number	:	313-831-8438

Provider Business Practice Location Address
First Line	:	4727 SAINT ANTOINE ST
Second Line	:	SUITE 210
City	:	DETROIT
State	:	MI
Zip	:	48201-1461
Country	:	US
Telephone Number	:	313-831-3066
Fax Number	:	313-831-8438

Authorized Official
Title or Position	:	PHYSICAN
Name	:	BRENT WINSTON GILLUM
Credential	:	D.O.
Telephone Number	:	313-831-3066

Provider Enumeration Date	:	06/06/2006
Last Update Date	:	11/07/2007

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Directions to “BRENT W GILLUM D O PLC ” Practice Location

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