Provider Demographics
NPI:1760504963
Name:GALICH, KRISTINE MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTINE
Middle Name:MARIE
Last Name:GALICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:M
Other - Last Name:GERBUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:9228 S MINGO RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-5718
Mailing Address - Country:US
Mailing Address - Phone:918-392-7575
Mailing Address - Fax:918-615-3465
Practice Address - Street 1:9228 S MINGO RD
Practice Address - Street 2:SUITE 103
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-5718
Practice Address - Country:US
Practice Address - Phone:918-392-7575
Practice Address - Fax:918-615-3465
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK28674207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200422170AMedicaid
OKOKA103771Medicare PIN