Provider Demographics
NPI:1376553222
Name:GALLOWAY, RICHARD J (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
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 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-296-2780
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:5909 US HIGHWAY 49
Practice Address - Street 2:SUITE 30
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401
Practice Address - Country:US
Practice Address - Phone:601-296-2780
Practice Address - Fax:601-296-2781
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14592207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00115186Medicaid
MS640507572AKOtherAMERICAN ADMIN GROUP
MS640507572AKOtherAMERICAN ADMIN GROUP
MS460000003Medicare PIN
MS00115186Medicaid