Provider Demographics
NPI:1780045351
Name:GALLEGLY, MATTHEW SHANE
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:SHANE
Last Name:GALLEGLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10664 WOLF AVE NE
Mailing Address - Street 2:
Mailing Address - City:HARTVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44632-8631
Mailing Address - Country:US
Mailing Address - Phone:330-877-3888
Mailing Address - Fax:
Practice Address - Street 1:10664 WOLF AVE NE
Practice Address - Street 2:
Practice Address - City:HARTVILLE
Practice Address - State:OH
Practice Address - Zip Code:44632-8631
Practice Address - Country:US
Practice Address - Phone:330-877-3888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-10
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer