Basic Information
| Provider Information | |||||||||
| NPI: | 1558404343 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GILLIAM | ||||||||
| FirstName: | JAI | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 910670 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405910670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8599714685 | ||||||||
| FaxNumber: | 8599714602 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 PROVIDENCE WAY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | NICHOLASVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403566031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592605370 | ||||||||
| FaxNumber: | 8592605379 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 12/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 39604 | KY | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | 39604 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64111156 | 05 | KY | MEDICAID |