Basic Information
| Provider Information | |||||||||
| NPI: | 1275583650 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILLIAM | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 64442 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212644442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107061372 | ||||||||
| FaxNumber: | 4107064619 | ||||||||
| Practice Location | |||||||||
| Address1: | 22 S GREENE ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212011544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107061372 | ||||||||
| FaxNumber: | 4107064619 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 11/15/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | D50956 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 3810011136 | 05 | WV | MEDICAID | 608175-01 & 02 | 01 | MD | BLUE CROSS/BLUE SHIELD | OTHER | 182200400 | 05 | MD | MEDICAID | 1275583650 | 05 | DE | MEDICAID |