Provider Demographics
NPI:1083694293
Name:GALLAGHER, SUSAN A (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:A
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SUSAN
Other - Middle Name:A
Other - Last Name:GALLAGHER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:149 E WATER ST
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-2525
Mailing Address - Country:US
Mailing Address - Phone:419-625-0925
Mailing Address - Fax:419-625-1994
Practice Address - Street 1:149 E WATER ST
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-2525
Practice Address - Country:US
Practice Address - Phone:419-625-0925
Practice Address - Fax:419-625-1994
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH46193207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0469792Medicaid
OHA80113Medicare UPIN
OH0469792Medicaid
OH110029350Medicare PIN