Provider Demographics
NPI:1790816189
Name:GAILIS, GLENN G (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:G
Last Name:GAILIS
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 1:1905 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-2638
Mailing Address - Country:US
Mailing Address - Phone:541-882-4691
Mailing Address - Fax:541-883-5211
Practice Address - Street 1:1905 MAIN ST
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-2638
Practice Address - Country:US
Practice Address - Phone:541-882-4691
Practice Address - Fax:541-883-5211
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD08780207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR239756Medicaid
OR239756Medicaid
OR08WCJJBGMedicare ID - Type Unspecified