Provider Demographics
NPI:1831125657
Name:GALLAGHER, STANLEY C (DO)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:C
Last Name:GALLAGHER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 ORCHARD DR
Mailing Address - Street 2:
Mailing Address - City:SISSETON
Mailing Address - State:SD
Mailing Address - Zip Code:57262-2312
Mailing Address - Country:US
Mailing Address - Phone:605-698-7681
Mailing Address - Fax:605-698-3493
Practice Address - Street 1:205 ORCHARD DR
Practice Address - Street 2:
Practice Address - City:SISSETON
Practice Address - State:SD
Practice Address - Zip Code:57262-2312
Practice Address - Country:US
Practice Address - Phone:605-698-7681
Practice Address - Fax:605-698-3493
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN23330207Q00000X
ND3994207Q00000X
SD3948207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN123088300Medicaid
SD53440220Medicaid
MN0123343OtherMEDICA
ND17531Medicaid
MN1001189OtherPREFERRED ONE
MN106824OtherUCARE
MNHP21653OtherHEALTHPARTNERS
MN123088300Medicaid
MNC07780Medicare Oscar/Certification
SDS102233Medicare Oscar/Certification