Provider Demographics
NPI:1477529436
Name:RUSSELLVILLE DERMATOLOGY CLINIC PA
Entity Type:Organization
Organization Name:RUSSELLVILLE DERMATOLOGY CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:W
Authorized Official - Last Name:GALLOWAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-968-6969
Mailing Address - Street 1:PO BOX 843
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-0843
Mailing Address - Country:US
Mailing Address - Phone:479-968-6969
Mailing Address - Fax:479-968-4290
Practice Address - Street 1:1602 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-2720
Practice Address - Country:US
Practice Address - Phone:479-968-6969
Practice Address - Fax:479-968-4290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC0841207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR110005002Medicaid
AR110005002Medicaid
ARD79437Medicare UPIN
AR5F719Medicare PIN