Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207QA0401X | Family Doctor - Addiction Medicine | XG4336702 | MD |
N | 363LA2200X | Nurse Practitioner - Adult Health | R209821 | MD |
Y | 363LP2300X | Nurse Practitioner - Primary Care | R209821 | MD |
NPI | 1033644554 |
---|---|
Provider Name | Mr. Lee Elliot Gilman |
First Address | Baltimore, MD 21224-2734 |
Second Address | Baltimore, MD 21224-2734 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/04/2017 |
Last Update Date | 20/10/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
126407960 | (05) | MD |
MG4336702 | DEA (01) | |
R209821 | MARYLAND BOARD OF NURSING LICENSE (01) | MD |
XG4336702 | DEA BUPRENORPHINE WAIVER (01) |