Healthcare Provider Details

I. General information

NPI: 1033644554
Provider Name (Legal Business Name): LEE ELLIOT GILMAN MSN-AGNP, NP-C, RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2017
Last Update Date: 03/07/2023
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 EASTERN AVE BLDG EAST2ND
BALTIMORE MD
21224-2734
US

IV. Provider business mailing address

5200 EASTERN AVE BLDG EAST
BALTIMORE MD
21224-2734
US

V. Phone/Fax

Practice location:
  • Phone: 410-550-2999
  • Fax: 410-367-2442
Mailing address:
  • Phone: 410-550-2999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR209821
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberR209821
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR209821
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberXG4336702
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: