Healthcare Provider Details

I. General information

NPI: 1548716806
Provider Name (Legal Business Name): KEVIN ROBERT GILLIAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2016
Last Update Date: 08/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901-B PEACHTREE DUNWOODY ROAD
ATLANTA GA
30328-7156
US

IV. Provider business mailing address

5901-B PEACHTREE DUNWOODY ROAD
ATLANTA GA
30328-7156
US

V. Phone/Fax

Practice location:
  • Phone: 404-252-9751
  • Fax: 404-255-5783
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License NumberRN252629
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: