MEDICARE: MR. THOMAS E GILHAM II IDC

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	1710I1002X	Independent Duty Corpsman	1710I1002X

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1710I1002X	OTHER		INDEPENDENT DUTY CORPSMAN

General Provider Information

NPI Number	:	1508828161
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. THOMAS E GILHAM II IDC

Provider Business Mailing Address
First Line	:	5503 MARVIN SHIELDS BLVD
Second Line	:
City	:	GULFPORT
State	:	MS
Zip	:	39501-9007
Country	:	US
Telephone Number	:	228-871-2810
Fax Number	:

Provider Business Practice Location Address
First Line	:	5503 MARVIN SHIELDS BLVD
Second Line	:
City	:	GULFPORT
State	:	MS
Zip	:	39501-9007
Country	:	US
Telephone Number	:	228-871-2810
Fax Number	:

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

Provider Enumeration Date	:	04/06/2006
Last Update Date	:	07/10/2007

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