Basic Information
| Provider Information | |||||||||
| NPI: | 1609847292 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GALLANTER | ||||||||
| FirstName: | TISHA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 655 W 8TH ST | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322096511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9049829586 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 655 W 8TH ST | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322096511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042445044 | ||||||||
| FaxNumber: | 9042444508 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2006 | ||||||||
| LastUpdateDate: | 08/10/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 146L00000X | 194584 | FL | N | Emergency Medical Service Providers | Emergency Medical Technician, Paramedic | 207P00000X | ME79093 | FL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 214121-1 | NY | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 045065 | GA | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 930080642 | 01 | RR CARE | OTHER | 00811885I | 05 | GA | MEDICAID | 000811885H | 05 | GA | MEDICAID | 256861600 | 05 | FL | MEDICAID | P00242437 | 01 | FL | RAILROAD MEDICARE | OTHER | 49209 | 01 | FL | BCBS | OTHER |