Provider Demographics
NPI:1124004817
Name:GALLMORE, KENNETH B II (DO)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:B
Last Name:GALLMORE
Suffix:II
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:28050 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-5919
Practice Address - Country:US
Practice Address - Phone:947-521-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013600207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700F314390OtherBLUE SHIELD
MI700H219150OtherBLUE SHIELD
MI1124004817Medicaid
MIH21829Medicare UPIN
MI700F314390OtherBLUE SHIELD
MI1124004817Medicaid