Healthcare Provider Details

I. General information

NPI: 1841372273
Provider Name (Legal Business Name): PHILLIP SCOTT GILLIAM PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 07/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 W TRUMAN RD
INDEPENDENCE MO
64050-3436
US

IV. Provider business mailing address

PO BOX 838
SHAWNEE MISSION KS
66201-0838
US

V. Phone/Fax

Practice location:
  • Phone: 816-836-6901
  • Fax: 816-836-4400
Mailing address:
  • Phone: 913-469-4244
  • Fax: 913-469-1939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2005017775
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2005017775
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: