=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568555480
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STUART W. GILLIM MDPC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2006
-----------------------------------------------------
Last Update Date | 10/02/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1969 TIMMERMAN HILL RD.
-----------------------------------------------------
City | CORTLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-835-6570
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1969 TIMMERMAN HILL RD.
-----------------------------------------------------
City | CORTLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-835-6570
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. STUART WILLIAM GILLIM
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 607-835-6570
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 108764
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------