Basic Information
| Provider Information | |||||||||
| NPI: | 1003817404 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GALL | ||||||||
| FirstName: | CLIFFORD | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2609 GLENN HENDREN DR | ||||||||
| Address2: | |||||||||
| City: | LIBERTY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640683313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8167817730 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2521 GLENN HENDREN DR STE 108 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640683388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8167813515 | ||||||||
| FaxNumber: | 8167813517 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 207T00000X | 04 23541 | KS | N | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | MD R4P55 | MO | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 17554034 | 01 | MO | BCBS | OTHER |