Basic Information
Provider Information | |||||||||
NPI: | 1659764298 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GILLIS | ||||||||
FirstName: | JONATHAN | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 80 TECHNACENTER DR | ||||||||
Address2: | SUITE 300 | ||||||||
City: | MONTGOMERY | ||||||||
State: | AL | ||||||||
PostalCode: | 361176028 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3346255795 | ||||||||
FaxNumber: | 3343964905 | ||||||||
Practice Location | |||||||||
Address1: | 4900 IVEY RD NW STE 1001 | ||||||||
Address2: |   | ||||||||
City: | ACWORTH | ||||||||
State: | GA | ||||||||
PostalCode: | 301014106 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7709170924 | ||||||||
FaxNumber: | 7709170926 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/06/2015 | ||||||||
LastUpdateDate: | 03/16/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT011834 | GA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 13681075 | 01 | GA | CAQH | OTHER |