Basic Information
Provider Information
NPI: 1003003070
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GILL
FirstName: ANITA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 70 N COUNTRY RD
Address2:  
City: PORT JEFFERSON
State: NY
PostalCode: 117772161
CountryCode: US
TelephoneNumber: 6316867970
FaxNumber: 6316867831
Practice Location
Address1: 70 N COUNTRY RD
Address2:  
City: PORT JEFFERSON
State: NY
PostalCode: 117772161
CountryCode: US
TelephoneNumber: 6316867970
FaxNumber: 6316867831
Other Information
ProviderEnumerationDate: 10/03/2007
LastUpdateDate: 11/23/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
2084N0400X246379NYY Allopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
2084N0600X246379NYN Allopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology

No ID Information.


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