Provider Demographics
NPI:1538212311
Name:GARY R. KILGO, M.D. , P.C. KILGO CLINIC
Entity type:Organization
Organization Name:GARY R. KILGO, M.D. , P.C. KILGO CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:RODERICK
Authorized Official - Last Name:KILGO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-349-2223
Mailing Address - Street 1:527 MAIN AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35476-4417
Mailing Address - Country:US
Mailing Address - Phone:205-349-2223
Mailing Address - Fax:205-349-2310
Practice Address - Street 1:527 MAIN AVE
Practice Address - Street 2:SUITE E
Practice Address - City:NORTHPORT
Practice Address - State:AL
Practice Address - Zip Code:35476-4417
Practice Address - Country:US
Practice Address - Phone:205-349-2223
Practice Address - Fax:205-349-2310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL95292084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALC74466Medicare UPIN