Provider Demographics
NPI:1003817057
Name:GALLAGHER, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:GALLAGHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 GRAND AVENUE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2558
Mailing Address - Country:US
Mailing Address - Phone:607-729-8156
Mailing Address - Fax:607-729-3982
Practice Address - Street 1:4417 VESTAL PARKWAY EAST
Practice Address - Street 2:SUITE 201
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-3556
Practice Address - Country:US
Practice Address - Phone:607-770-7365
Practice Address - Fax:607-798-1835
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY189859-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01348874Medicaid
NY01348874Medicaid
NYJ400059298Medicare PIN