Provider Demographics
NPI:1023266574
Name:CHRISTINE L. GILLIAM, MD PA
Entity type:Organization
Organization Name:CHRISTINE L. GILLIAM, MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:L
Authorized Official - Last Name:GILLIAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-647-3838
Mailing Address - Street 1:502 MADISON OAK DR
Mailing Address - Street 2:SUITE 140
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-4084
Mailing Address - Country:US
Mailing Address - Phone:210-647-3838
Mailing Address - Fax:210-403-3166
Practice Address - Street 1:502 MADISON OAK DR
Practice Address - Street 2:SUITE 140
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4084
Practice Address - Country:US
Practice Address - Phone:210-647-3838
Practice Address - Fax:210-403-3166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-08
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM3234207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0048RROtherBLUE CROSS
TXOAO111Medicare PIN