Healthcare Provider Details

I. General information

NPI: 1710926670
Provider Name (Legal Business Name): BRENT W GILLUM D O PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 11/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4727 SAINT ANTOINE ST SUITE 210
DETROIT MI
48201-1461
US

IV. Provider business mailing address

4727 SAINT ANTOINE ST SUITE 210
DETROIT MI
48201-1461
US

V. Phone/Fax

Practice location:
  • Phone: 313-831-3066
  • Fax: 313-831-8438
Mailing address:
  • Phone: 313-831-3066
  • Fax: 313-831-8438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number007845
License Number StateMI

VIII. Authorized Official

Name: BRENT WINSTON GILLUM
Title or Position: PHYSICAN
Credential: D.O.
Phone: 313-831-3066