Basic Information
| Provider Information | |||||||||
| NPI: | 1952620460 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILLHAM | ||||||||
| FirstName: | MARIEL | ||||||||
| MiddleName: | |||||||||
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| Credential: | M. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 155 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283748710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107152164 | ||||||||
| FaxNumber: | 9107154493 | ||||||||
| Practice Location | |||||||||
| Address1: | 155 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283748710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107152164 | ||||||||
| FaxNumber: | 9107154493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2010 | ||||||||
| LastUpdateDate: | 12/04/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 01382 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 01382 | NC | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 18034 | 01 | NC | BCBS | OTHER | 1952620460 | 05 | NC | MEDICAID |