Basic Information
| Provider Information | |||||||||
| NPI: | 1043205024 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GALLOWAY | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | MSPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 PARK ST | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421011742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707964698 | ||||||||
| FaxNumber: | 2707823274 | ||||||||
| Practice Location | |||||||||
| Address1: | 165 NATCHEZ TRACE AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421037947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707964698 | ||||||||
| FaxNumber: | 2707823274 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2005 | ||||||||
| LastUpdateDate: | 05/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 004842 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 532436 | 01 | KY | ANTHEM | OTHER | 375713 | 01 | KY | ANTHEM | OTHER | 87001822 | 05 | KY | MEDICAID |