Basic Information
| Provider Information | |||||||||
| NPI: | 1427003508 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PALLEY | ||||||||
| FirstName: | GILBERT | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 649 | ||||||||
| Address2: | FORT DEFIANCE INDIAN HOSPITAL BOARD, INC. | ||||||||
| City: | FORT DEFIANCE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 865040649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287298000 | ||||||||
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| Practice Location | |||||||||
| Address1: | CORNER ROUTE N12 AND N7 | ||||||||
| Address2: | |||||||||
| City: | FORT DEFIANCE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 865040649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287298000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 06/05/2013 | ||||||||
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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 | 207P00000X | OS004517L | PA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00712028 | 05 | PA | MEDICAID |