Provider Demographics
NPI:1962484923
Name:GALLUP, RICHARD E (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:E
Last Name:GALLUP
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:250 W KENSINGTON RD
Mailing Address - Street 2:SUITE 1 A
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-1293
Mailing Address - Country:US
Mailing Address - Phone:847-483-0200
Mailing Address - Fax:847-483-0201
Practice Address - Street 1:250 W KENSINGTON RD
Practice Address - Street 2:SUITE 1 A
Practice Address - City:MOUNT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-1293
Practice Address - Country:US
Practice Address - Phone:847-483-0200
Practice Address - Fax:847-483-0201
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2010-10-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036090453207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG13862Medicare UPIN