Healthcare Provider Details

I. General information

NPI: 1376168963
Provider Name (Legal Business Name): JOSEPH GILLAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2020
Last Update Date: 05/29/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 S 1ST AVE
MAYWOOD IL
60153-3328
US

IV. Provider business mailing address

2160 S 1ST AVE
MAYWOOD IL
60153-3328
US

V. Phone/Fax

Practice location:
  • Phone: 888-548-7888
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number125.083147
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: