MEDICARE: MR. JAMISON GILMORE II

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	172A00000X	Driver		OH

General Provider Information

NPI Number	:	1164120093
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAMISON GILMORE II

Provider Business Mailing Address
First Line	:	6370 BRAXTON PL
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45459-2531
Country	:	US
Telephone Number	:	937-245-4366
Fax Number	:

Provider Business Practice Location Address
First Line	:	6370 BRAXTON PL
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45459-2531
Country	:	US
Telephone Number	:	937-245-4366
Fax Number	:

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

Provider Enumeration Date	:	02/20/2023
Last Update Date	:	02/20/2023

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Directions to “ MR. JAMISON GILMORE II ” Practice Location

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