Provider Demographics
NPI:1407018948
Name:GALLACHER, STACEY E (MD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:E
Last Name:GALLACHER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 HOWARD AVE
Mailing Address - Street 2:ROOM YPB 133
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1369
Mailing Address - Country:US
Mailing Address - Phone:203-737-2348
Mailing Address - Fax:203-737-4687
Practice Address - Street 1:800 HOWARD AVE
Practice Address - Street 2:ROOM YPB 133
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1369
Practice Address - Country:US
Practice Address - Phone:203-737-2348
Practice Address - Fax:203-737-4687
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-26
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILP01350207X00000X
RI14191207X00000X
CT052800207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
RISG92817Medicaid