Basic Information
| Provider Information | |||||||||
| NPI: | 1851397236 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILLEN | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 749 | ||||||||
| Address2: | |||||||||
| City: | MORRISVILLE | ||||||||
| State: | VT | ||||||||
| PostalCode: | 056610749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028518704 | ||||||||
| FaxNumber: | 8028518716 | ||||||||
| Practice Location | |||||||||
| Address1: | 609 WASHINGTON HWY | ||||||||
| Address2: | |||||||||
| City: | MORRISVILLE | ||||||||
| State: | VT | ||||||||
| PostalCode: | 056618652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028885639 | ||||||||
| FaxNumber: | 8028886040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2005 | ||||||||
| LastUpdateDate: | 10/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35-03-6140-G | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 35036140 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2056644 | 05 | OH | MEDICAID |