Basic Information
Provider Information
NPI: 1952625576
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: GILLEN
FirstName: JACOB
MiddleName: R
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1906 BELLEVIEW AVE SE
Address2:  
City: ROANOKE
State: VA
PostalCode: 240141838
CountryCode: US
TelephoneNumber: 5409817000
FaxNumber: 5409818429
Practice Location
Address1: 1906 BELLEVIEW AVE SE
Address2:  
City: ROANOKE
State: VA
PostalCode: 24014
CountryCode: US
TelephoneNumber: 5409817000
FaxNumber: 5409818429
Other Information
ProviderEnumerationDate: 03/25/2010
LastUpdateDate: 08/11/2021
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 08/11/2021

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
390200000X4301109915MIN Student, Health CareStudent in an Organized Health Care Education/Training Program 
2086S0102X0101264407VAY Allopathic & Osteopathic PhysiciansSurgerySurgical Critical Care

No ID Information.


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