Healthcare Provider Details

I. General information

NPI: 1790773091
Provider Name (Legal Business Name): JEFFREY GILLUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 02/01/2010
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

43800 GARFIELD RD
CLINTON TWP MI
48038-1136
US

V. Phone/Fax

Practice location:
  • Phone: 313-831-3066
  • Fax: 313-831-8438
Mailing address:
  • Phone: 800-848-0202
  • Fax: 586-226-6949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number4301041555
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: