Provider Demographics
NPI:1841475803
Name:NORTHWEST COSMETIC SURGERY, LLC
Entity type:Organization
Organization Name:NORTHWEST COSMETIC SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:LYLE
Authorized Official - Last Name:GALLAGHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-283-1845
Mailing Address - Street 1:777 SW MILL VIEW WAY STE 250
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1140
Mailing Address - Country:US
Mailing Address - Phone:541-728-3184
Mailing Address - Fax:
Practice Address - Street 1:777 SW MILL VIEW WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1140
Practice Address - Country:US
Practice Address - Phone:541-388-1022
Practice Address - Fax:541-322-7002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD21961208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR112945Medicare PIN