MEDICARE: ROY JACK GILLISPIE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	R2A36	MO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	080192592	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	7500	OTHER		BCBS

General Provider Information

NPI Number	:	1023052115
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROY JACK GILLISPIE MD

Provider Business Mailing Address
First Line	:	5136 HWY 265
Second Line	:
City	:	BRANSON
State	:	MO
Zip	:	65616-9099
Country	:	US
Telephone Number	:	417-338-0960
Fax Number	:	417-338-0968

Provider Business Practice Location Address
First Line	:	5136 HWY 265
Second Line	:
City	:	BRANSON
State	:	MO
Zip	:	65616-9099
Country	:	US
Telephone Number	:	417-338-0960
Fax Number	:	417-338-0968

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2006
Last Update Date	:	05/01/2013

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