Provider Demographics
NPI:1063583300
Name:GALLAGHER, REBECCA Z (MD)
Entity type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:Z
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32645 WEST ESKER LN
Mailing Address - Street 2:
Mailing Address - City:NASHOTAH
Mailing Address - State:WI
Mailing Address - Zip Code:53058
Mailing Address - Country:US
Mailing Address - Phone:262-367-1717
Mailing Address - Fax:262-458-4547
Practice Address - Street 1:4607 VETTELSON ROAD
Practice Address - Street 2:
Practice Address - City:HARTLAND
Practice Address - State:WI
Practice Address - Zip Code:53029
Practice Address - Country:US
Practice Address - Phone:262-367-1717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50254207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1063583300Medicaid