Provider Demographics
NPI:1750472387
Name:GALLAGHER, JOHN THOMAS (EDD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:THOMAS
Last Name:GALLAGHER
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6100 NEWPORT RD
Mailing Address - Street 2:SUITE 222
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-9235
Mailing Address - Country:US
Mailing Address - Phone:269-324-1248
Mailing Address - Fax:269-324-1263
Practice Address - Street 1:6100 NEWPORT RD
Practice Address - Street 2:SUITE 222
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-9235
Practice Address - Country:US
Practice Address - Phone:269-324-1248
Practice Address - Fax:269-324-1263
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301000929103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680C94538OtherBLUE CROSS BLUE SHIELD
MIOC94538Medicare ID - Type Unspecified
MIR77037Medicare UPIN