1811314040 NPI number — WILLIAM FEATHERSTON GILMORE III MD

Table of content: WILLIAM FEATHERSTON GILMORE III MD (NPI 1811314040)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811314040 NPI number — WILLIAM FEATHERSTON GILMORE III MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GILMORE
Provider First Name:
WILLIAM
Provider Middle Name:
FEATHERSTON
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GILMORE
Provider Other First Name:
BEAU
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1811314040
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3181 SW SAM JACKSON PARK RD # L579
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97239-3011
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-202-2352
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2084 NE PROFESSIONAL CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97701-6077
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
542-383-3005
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/26/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  MD187372 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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