Basic Information
| Provider Information | |||||||||
| NPI: | 1407904717 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILMOUR | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.C. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GILMOUR | ||||||||
| OtherFirstName: | GREGORY | ||||||||
| OtherMiddleName: | JOHN | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 804 SERVICE RD STE A109B | ||||||||
| Address2: | |||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488247015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173645260 | ||||||||
| FaxNumber: | 5173645251 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 E MICHIGAN AVE STE 520 | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489121899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173645356 | ||||||||
| FaxNumber: | 5173645251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2007 | ||||||||
| LastUpdateDate: | 06/17/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 4301109712 | MI | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.