Healthcare Provider Details

I. General information

NPI: 1417072422
Provider Name (Legal Business Name): MICHAEL GILLMORE RNFA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 DEERPATH
CHARLESTON IL
61920-9427
US

IV. Provider business mailing address

211 E FAYETTE AVE
EFFINGHAM IL
62401-3614
US

V. Phone/Fax

Practice location:
  • Phone: 217-345-2727
  • Fax: 217-345-2781
Mailing address:
  • Phone: 217-343-8721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: