Provider Demographics
NPI:1922258029
Name:SAMUEL S. GALLEY, M.D.,INC.
Entity Type:Organization
Organization Name:SAMUEL S. GALLEY, M.D.,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN, CEO
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:SETORNYO
Authorized Official - Last Name:GALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-750-6959
Mailing Address - Street 1:PO BOX 801
Mailing Address - Street 2:
Mailing Address - City:HARBOR CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90710-0801
Mailing Address - Country:US
Mailing Address - Phone:310-518-1859
Mailing Address - Fax:310-518-1859
Practice Address - Street 1:8473 S VAN NESS AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90305-1550
Practice Address - Country:US
Practice Address - Phone:323-750-6959
Practice Address - Fax:323-778-4862
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAMUEL S. GALLEY, M.D., INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-25
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG52589261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G525891Medicaid
CA00G525891Medicaid
CAG52589Medicare Oscar/Certification