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General NPI Number Information
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NPI Number | 1891003802
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Entity Type | Organization
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Legal Business Name | SHANE GILLIAM, M.D., P.A.
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Dates
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Enumeration Date | 09/24/2010
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Last Update Date | 09/24/2010
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Provider Practice Location Address
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Address Line | 630 N GRAHAM STREET
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City | STEPHENVILLE
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State | TX
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Zip | 76401-3552
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Country | US
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Telephone | 254-965-8760
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Fax | 254-965-8766
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Provider Business Mailing Address
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Address Line | 630 N GRAHAM STREET
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City | STEPHENVILLE
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State | TX
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Zip | 76401-3552
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Country | US
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Telephone | 254-965-8760
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Fax | 254-965-8766
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Authorized Official
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Title or Position | PHYSICIAN/OWNER
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Name | DR. LESLIE SHANE GILLIAM
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Credential | M.D.
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Telephone | 254-965-8760
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | L7278
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License Number State | TX
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