Healthcare Provider Details

I. General information

NPI: 1962562470
Provider Name (Legal Business Name): ANNA C GILLIAM DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 MARSHALL AVE
ANDERSON SC
29621-5835
US

IV. Provider business mailing address

408 MARSHALL AVE
ANDERSON SC
29621-5835
US

V. Phone/Fax

Practice location:
  • Phone: 864-224-1836
  • Fax: 864-224-1802
Mailing address:
  • Phone: 864-224-1836
  • Fax: 864-224-1802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number065
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: