Healthcare Provider Details

I. General information

NPI: 1578143608
Provider Name (Legal Business Name): MARY ROXANNE GILLAM DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2021
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 W 13 MILE RD
ROYAL OAK MI
48073-6712
US

IV. Provider business mailing address

3601 W 13 MILE RD
ROYAL OAK MI
48073-6712
US

V. Phone/Fax

Practice location:
  • Phone: 248-898-0727
  • Fax:
Mailing address:
  • Phone: 248-898-0727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number5101027958
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: