Provider Demographics
NPI:1932111390
Name:GALLAGHER, SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:GALLAGHER
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 1:3404 WAKE FOREST RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-7340
Mailing Address - Country:US
Mailing Address - Phone:919-576-8155
Mailing Address - Fax:919-576-8154
Practice Address - Street 1:3404 WAKE FOREST RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7340
Practice Address - Country:US
Practice Address - Phone:919-576-8155
Practice Address - Fax:919-576-8154
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME86585208600000X
NC2011-01979208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL46697OtherBLUE CROSS BLUE SHIELD
FL270032800Medicaid
NC5919688Medicaid
FL46697OtherBLUE CROSS BLUE SHIELD
NC5919688Medicaid
FL46691ZMedicare PIN
FL270032800Medicaid