Provider Demographics
NPI:1629117411
Name:JAMES W GALLAGHER DPM
Entity Type:Organization
Organization Name:JAMES W GALLAGHER DPM
Other - Org Name:SUPERIOR FOOT & ANKLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:L
Authorized Official - Last Name:FRUSTAGLIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-225-4782
Mailing Address - Street 1:1414 W FAIR AVE STE 290
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-2683
Mailing Address - Country:US
Mailing Address - Phone:906-225-4782
Mailing Address - Fax:906-225-7835
Practice Address - Street 1:1414 W FAIR AVE STE 290
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2683
Practice Address - Country:US
Practice Address - Phone:906-225-4782
Practice Address - Fax:906-225-7835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001221213EP1101X, 213ES0000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Not Answered213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports MedicineGroup - Single Specialty
Not Answered213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4393452Medicaid
MI0N49330Medicare ID - Type Unspecified
MI4393452Medicaid