Healthcare Provider Details

I. General information

NPI: 1265871867
Provider Name (Legal Business Name): AKIRA WILLIAM GILLINGHAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2013
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 E SUPERIOR ST # 5-2370
CHICAGO IL
60611-2914
US

IV. Provider business mailing address

250 E SUPERIOR ST # 5-2370
CHICAGO IL
60611-2914
US

V. Phone/Fax

Practice location:
  • Phone: 312-472-3874
  • Fax: 312-472-3690
Mailing address:
  • Phone: 312-472-3874
  • Fax: 312-472-3690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number036.142279
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: