Basic Information
| Provider Information | |||||||||
| NPI: | 1003817057 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GALLAGHER | ||||||||
| FirstName: | KEVIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 346 GRAND AVENUE | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137902558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077298156 | ||||||||
| FaxNumber: | 6077293982 | ||||||||
| Practice Location | |||||||||
| Address1: | 4417 VESTAL PARKWAY EAST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | VESTAL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 138503556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077707365 | ||||||||
| FaxNumber: | 6077981835 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2005 | ||||||||
| LastUpdateDate: | 09/19/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 189859-1 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01348874 | 05 | NY | MEDICAID |