MEDICARE: BRUCE DEVIN GILLILAND O.D.

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	152WL0500X	Low Vision Rehabilitation Optometrist	1593	TN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
5	P00317714	OTHER	TN	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4102823	OTHER	TN	BLUE CROSS BLUE SHILED
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184622441
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRUCE DEVIN GILLILAND O.D.

Provider Business Mailing Address
First Line	:	715 CALLAHAN DR
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37912-1302
Country	:	US
Telephone Number	:	865-687-1232
Fax Number	:	865-687-8256

Provider Business Practice Location Address
First Line	:	715 CALLAHAN DR
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37912-1302
Country	:	US
Telephone Number	:	865-687-1232
Fax Number	:	865-687-8256

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

Provider Enumeration Date	:	07/11/2005
Last Update Date	:	06/13/2014

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