Healthcare Provider Details

I. General information

NPI: 1366430894
Provider Name (Legal Business Name): MICHAEL TIFFANY GILLETTE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 08/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 BLYTHE BLVD
CHARLOTTE NC
28203-5812
US

IV. Provider business mailing address

PO BOX 36351
CHARLOTTE NC
28236-6351
US

V. Phone/Fax

Practice location:
  • Phone: 704-355-2372
  • Fax: 704-355-6692
Mailing address:
  • Phone: 704-377-5772
  • Fax: 704-377-3389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number25294
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number25294
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: