Healthcare Provider Details

I. General information

NPI: 1144511999
Provider Name (Legal Business Name): ROGER GILG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2011
Last Update Date: 04/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1089 N WISNER ST
JACKSON MI
49202-3143
US

IV. Provider business mailing address

1089 N WISNER ST
JACKSON MI
49202-3143
US

V. Phone/Fax

Practice location:
  • Phone: 517-782-0574
  • Fax: 517-787-5592
Mailing address:
  • Phone: 517-782-0574
  • Fax: 517-787-5592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302020698
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: