Basic Information
Provider Information | |||||||||
NPI: | 1457452237 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GALLAWAY | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | F | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 36 W LAKE RD | ||||||||
Address2: |   | ||||||||
City: | MEDFORD | ||||||||
State: | NJ | ||||||||
PostalCode: | 080558104 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8567977922 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1200 W GODFREY AVE | ||||||||
Address2: |   | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191413323 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2152766000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/26/2006 | ||||||||
LastUpdateDate: | 02/15/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WP0200X | OEG001315 | PA | Y |   | Eye and Vision Services Providers | Optometrist | Pediatrics |
ID Information
ID | Type | State | Issuer | Description | BLUE SHIELD | 01 | PA | 186014 | OTHER | 2248 | 01 | PA | HMO | OTHER |