Basic Information
| Provider Information | |||||||||
| NPI: | 1649268723 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JILLY | ||||||||
| FirstName: | GABOR | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13128 N 94TH DR | ||||||||
| Address2: | SUITE100 | ||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853814252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238768816 | ||||||||
| FaxNumber: | 6239336739 | ||||||||
| Practice Location | |||||||||
| Address1: | 13128 N 94TH DR | ||||||||
| Address2: | NO 100 | ||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853814252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238768816 | ||||||||
| FaxNumber: | 6239336739 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 08/23/2012 | ||||||||
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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 | 207RC0000X | 22594 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | WCFKQ | 01 | AZ | SUN HEALTH PHYSICIANS | OTHER | 173948 | 05 | AZ | MEDICAID |