Basic Information
| Provider Information | |||||||||
| NPI: | 1669479390 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILLILAND | ||||||||
| FirstName: | SHARON | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CHEEK | ||||||||
| OtherFirstName: | SHARON | ||||||||
| OtherMiddleName: | GILLILAND | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 18341 US HIGHWAY 41 | ||||||||
| Address2: | |||||||||
| City: | LANSE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 499468024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9065246118 | ||||||||
| FaxNumber: | 9065246218 | ||||||||
| Practice Location | |||||||||
| Address1: | 18341 US HIGHWAY 41 | ||||||||
| Address2: | |||||||||
| City: | LANSE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 499468024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9065246118 | ||||||||
| FaxNumber: | 9065246218 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 12/09/2011 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 01036061 | IN | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 4301099797 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 100118810 | 05 | IN | MEDICAID | 4301099797 | 01 | MI | MICHIGAN PHYSICIAN LICENSE | OTHER | 1669479390 | 05 | MI | MEDICAID |