Provider Demographics
NPI:1609833979
Name:GALLE, PHILLIP CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:CHARLES
Last Name:GALLE
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 1:340 W MILLER STREET
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702
Mailing Address - Country:US
Mailing Address - Phone:217-523-4700
Mailing Address - Fax:217-523-9025
Practice Address - Street 1:340 W MILLER STREET
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702
Practice Address - Country:US
Practice Address - Phone:217-523-4700
Practice Address - Fax:217-523-9025
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360694081207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
729511Medicare ID - Type Unspecified
D15524Medicare UPIN