Provider Demographics
NPI:1811924871
Name:GALLAGHER, EDGAR GIVENS JR (MD)
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:GIVENS
Last Name:GALLAGHER
Suffix:JR
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 1:255 MEMORIAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546
Mailing Address - Country:US
Mailing Address - Phone:910-353-7848
Mailing Address - Fax:910-353-5052
Practice Address - Street 1:255 MEMORIAL DRIVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546
Practice Address - Country:US
Practice Address - Phone:910-353-7848
Practice Address - Fax:910-353-5052
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14660208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8934378Medicaid
206494Medicare ID - Type Unspecified
D33121Medicare UPIN