Basic Information
| Provider Information | |||||||||
| NPI: | 1912109018 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILLILAND | ||||||||
| FirstName: | LAWRENCE | ||||||||
| MiddleName: | LEA COCKROFT | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GILLILAND | ||||||||
| OtherFirstName: | LAWRENCE | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 3262 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658083262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178853888 | ||||||||
| FaxNumber: | 4178817268 | ||||||||
| Practice Location | |||||||||
| Address1: | 3850 S NATIONAL AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658075287 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172696170 | ||||||||
| FaxNumber: | 4172696992 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2007 | ||||||||
| LastUpdateDate: | 07/20/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 0101247434 | VA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085U0001X | 390200000X | TN | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085R0202X | 2011017818 | MO | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.