Provider Demographics
NPI:1063618171
Name:KEVIN L GALLOWAY, DO PLLC
Entity type:Organization
Organization Name:KEVIN L GALLOWAY, DO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:GALLOWAY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:601-376-2999
Mailing Address - Street 1:1860 CHADWICK DR
Mailing Address - Street 2:300
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-3463
Mailing Address - Country:US
Mailing Address - Phone:601-376-2999
Mailing Address - Fax:601-376-2989
Practice Address - Street 1:1860 CHADWICK DR
Practice Address - Street 2:300
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-3463
Practice Address - Country:US
Practice Address - Phone:601-376-2999
Practice Address - Fax:601-376-2989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16585207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00123174Medicaid