Provider Demographics
NPI:1306828538
Name:GALLUP, KENNETH RAYNOR JR (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:RAYNOR
Last Name:GALLUP
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:3001 LYNDHURST AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103
Mailing Address - Country:US
Mailing Address - Phone:336-765-0383
Mailing Address - Fax:336-768-1737
Practice Address - Street 1:100 CHATHAM MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:ELKIN
Practice Address - State:NC
Practice Address - Zip Code:28621-2445
Practice Address - Country:US
Practice Address - Phone:336-527-7198
Practice Address - Fax:336-527-8379
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2016-08-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC18642207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC34396Medicaid
NC34396Medicaid
C83958Medicare UPIN