Provider Demographics
NPI:1356580930
Name:GALLOGLY, RANDY A (IDC)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:A
Last Name:GALLOGLY
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 BALTIC RD
Mailing Address - Street 2:
Mailing Address - City:NORTH FRANKLIN
Mailing Address - State:CT
Mailing Address - Zip Code:06254-1402
Mailing Address - Country:US
Mailing Address - Phone:860-867-7514
Mailing Address - Fax:
Practice Address - Street 1:26 BALTIC RD
Practice Address - Street 2:
Practice Address - City:NORTH FRANKLIN
Practice Address - State:CT
Practice Address - Zip Code:06254-1402
Practice Address - Country:US
Practice Address - Phone:860-694-2117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-05
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman