Provider Demographics
NPI:1336250042
Name:GALLAGHER, BRIAN MICHAEL (PA)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:MICHAEL
Last Name:GALLAGHER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3270 DOBSON DR
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706-1675
Mailing Address - Country:US
Mailing Address - Phone:989-450-5641
Mailing Address - Fax:
Practice Address - Street 1:901 S HENRY ST
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-5076
Practice Address - Country:US
Practice Address - Phone:989-894-9000
Practice Address - Fax:989-894-9018
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004365363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N99660Medicare ID - Type Unspecified
MIQ25068Medicare UPIN