MEDICARE: RICHARD J GILL PTA

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	225200000X	Physical Therapy Assistant	5502004016	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5502004016	OTHER	MI	STATE OF MICHIGAN

General Provider Information

NPI Number	:	1982331930
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD J GILL PTA

Provider Business Mailing Address
First Line	:	2240 E HILL RD STE H
Second Line	:
City	:	GRAND BLANC
State	:	MI
Zip	:	48439-5425
Country	:	US
Telephone Number	:	810-606-8766
Fax Number	:	810-606-8770

Provider Business Practice Location Address
First Line	:	2240 E HILL RD STE H
Second Line	:
City	:	GRAND BLANC
State	:	MI
Zip	:	48439-5425
Country	:	US
Telephone Number	:	810-606-8766
Fax Number	:	810-606-8770

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

Provider Enumeration Date	:	08/01/2022
Last Update Date	:	08/01/2022

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