Basic Information
Provider Information | |||||||||
NPI: | 1811909146 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GALLOWAY | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1365 CLIFTON RD NE | ||||||||
Address2: | BLDG A | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303221013 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4047787777 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1365 CLIFTON RD NE | ||||||||
Address2: | BLDG A | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303221013 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4047787777 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/13/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
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 | 208600000X | 025752 | GA | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 515646 | 01 | GA | US HEALTHCARE | OTHER | 1170418 | 01 | GA | UNITED HEALTHCARE | OTHER | 260328 | 01 | GA | BCBS | OTHER | Y 19880601 | 01 | GA | PHCS | OTHER |