Healthcare Provider Details

I. General information

NPI: 1427096221
Provider Name (Legal Business Name): PATRICIA GILLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 10/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1106 ANNAPOLIS RD SUITE 310
ODENTON MD
21113-1637
US

IV. Provider business mailing address

1106 ANNAPOLIS RD SUITE 310
ODENTON MD
21113-1637
US

V. Phone/Fax

Practice location:
  • Phone: 410-874-1400
  • Fax:
Mailing address:
  • Phone: 410-874-1400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD43220
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: