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General NPI Number Information
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NPI Number | 1790773091
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Entity Type | Individual
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Provider Name | JEFFREY GILLUM MD
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Gender | Male
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Dates
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Enumeration Date | 10/11/2005
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Last Update Date | 02/01/2010
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Provider Practice Location Address
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Address Line | 4727 SAINT ANTOINE ST SUITE 210
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City | DETROIT
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State | MI
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Zip | 48201-1461
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Country | US
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Telephone | 313-831-3066
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Fax | 313-831-8438
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Provider Business Mailing Address
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Address Line | 43800 GARFIELD RD
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City | CLINTON TWP
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State | MI
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Zip | 48038-1136
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Country | US
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Telephone | 800-848-0202
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Fax | 586-226-6949
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | 4301041555
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License Number State | MI
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