Provider Demographics
NPI:1174574255
Name:GILL, ROBERT PATRICK (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:PATRICK
Last Name:GILL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:200 SAINT CLAIR AVE
Mailing Address - Street 2:GRAND LAKE PHYSICIAN PRACTICES
Mailing Address - City:SAINT MARYS
Mailing Address - State:OH
Mailing Address - Zip Code:45885-2400
Mailing Address - Country:US
Mailing Address - Phone:419-394-3387
Mailing Address - Fax:419-628-4307
Practice Address - Street 1:4463 STATE ROUTE 66
Practice Address - Street 2:
Practice Address - City:MINSTER
Practice Address - State:OH
Practice Address - Zip Code:45865-8727
Practice Address - Country:US
Practice Address - Phone:419-394-3387
Practice Address - Fax:419-628-9501
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2015-05-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OH35040370207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0385337Medicaid
OH2821576OtherMEDICAID LEGACY
OH1942630348OtherGROUP PTAN
OH9934723OtherMEDICARE ORGANIZATIONAL PTAN
OH9934723OtherMEDICARE ORGANIZATIONAL PTAN