Healthcare Provider Details

I. General information

NPI: 1376754200
Provider Name (Legal Business Name): MATTHEW T GILL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 02/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4320 SUWANEE DAM RD STE 200
SUWANEE GA
30024-1918
US

IV. Provider business mailing address

4320 SUWANEE DAM RD STE 200
SUWANEE GA
30024-1918
US

V. Phone/Fax

Practice location:
  • Phone: 404-297-4230
  • Fax: 678-710-9430
Mailing address:
  • Phone: 404-297-4230
  • Fax: 678-710-9430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number067303
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: