Basic Information
| Provider Information | |||||||||
| NPI: | 1609849868 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GILLY | ||||||||
| FirstName: | PHILIP | ||||||||
| MiddleName: | ALAIN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6773 W MAPLE RD | ||||||||
| Address2: | HENRY FORD MAPLEGROVE CENTER | ||||||||
| City: | WEST BLOOMFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483223013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486616100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6773 W MAPLE RD | ||||||||
| Address2: | HENRY FORD MAPLEGROVE CENTER | ||||||||
| City: | WEST BLOOMFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483223013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486616100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 10/17/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 180754 | NY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QA0401X | 4301098753 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01166201 | 05 | NY | MEDICAID |