=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467539775
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GILL FAMILY MEDICINE, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2006
-----------------------------------------------------
Last Update Date | 02/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2422 DANVILLE RD SW STE E
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35603-4221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-355-9040
-----------------------------------------------------
Fax | 256-355-9048
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5750
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35601-0750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-355-9040
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | ELAINE LADD GILL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 256-355-9040
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD.12215
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------