Basic Information
| Provider Information | |||||||||
| NPI: | 1124384920 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILLELAND | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751069 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751069 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2100 STANTONSBURG RD | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2527444184 | ||||||||
| FaxNumber: | 2527444125 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2012 | ||||||||
| LastUpdateDate: | 03/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | 2018-00969 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207P00000X | 2018-00969 | NC | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1124384920 | 05 | NC | MEDICAID | 19XB0 | 01 | NC | BCBS OF NC | OTHER | NN22820322 | 01 | NC | MEDICARE | OTHER |