Healthcare Provider Details

I. General information

NPI: 1326080375
Provider Name (Legal Business Name): ANGUS GILLIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 08/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 S BRYN MAWR AVE
BRYN MAWR PA
19010-3121
US

IV. Provider business mailing address

744 W MICHIGAN AVE
JACKSON MI
49201-1909
US

V. Phone/Fax

Practice location:
  • Phone: 610-526-3000
  • Fax: 517-787-4146
Mailing address:
  • Phone: 517-787-6440
  • Fax: 517-787-4146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD037670E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: