Provider Demographics
NPI:1407862410
Name:GALE, STEPHEN C (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:C
Last Name:GALE
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 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-302-2600
Mailing Address - Fax:208-302-2625
Practice Address - Street 1:999 N CURTIS ROAD
Practice Address - Street 2:STE 415
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706
Practice Address - Country:US
Practice Address - Phone:208-302-2600
Practice Address - Fax:208-302-2625
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM57182086S0127X
AZ403822086S0127X
IDM-143042086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G7468Medicare PIN
TXP00449561Medicare PIN
G90666Medicare UPIN
TX8G7468Medicare PIN
NJP01025992OtherRR MEDICARE
NJ0264318Medicaid
TXP00449561Medicare PIN
NJP01027340OtherRR MCR
NJ082151NAHMedicare PIN