Provider Demographics
NPI:1134128630
Name:GALLOWAY, JERRY E (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:E
Last Name:GALLOWAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 49847
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29649-0015
Mailing Address - Country:US
Mailing Address - Phone:864-943-2010
Mailing Address - Fax:864-323-0345
Practice Address - Street 1:202 OVERLAND DR
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-4069
Practice Address - Country:US
Practice Address - Phone:864-943-2010
Practice Address - Fax:864-323-0345
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10472207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC104728Medicaid
SC180046373OtherRAILROAD MEDICARE NUMBER
SCGP4102Medicaid
SCC604497563Medicare PIN
SCC60449Medicare UPIN