Healthcare Provider Details

I. General information

NPI: 1235642588
Provider Name (Legal Business Name): GILL MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2017
Last Update Date: 12/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 S FAIRMONT AVE STE 235
LODI CA
95240-5100
US

IV. Provider business mailing address

PO BOX 2597
LODI CA
95241-2597
US

V. Phone/Fax

Practice location:
  • Phone: 209-334-0799
  • Fax:
Mailing address:
  • Phone: 209-334-6583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA131215
License Number StateCA

VIII. Authorized Official

Name: RUBY KAUR SRAO
Title or Position: PRESIDENT
Credential: MD
Phone: 209-334-0799