Provider Demographics
NPI:1346295094
Name:GALLIWAY, STEVEN LEE (PAC)
Entity type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:LEE
Last Name:GALLIWAY
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2462 E HILL RD STE 2
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-5427
Mailing Address - Country:US
Mailing Address - Phone:810-584-7957
Mailing Address - Fax:949-695-4951
Practice Address - Street 1:2462 E HILL RD STE 2
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-5427
Practice Address - Country:US
Practice Address - Phone:810-584-7957
Practice Address - Fax:949-695-4951
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2024-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISG003407363AM0700X
MI5601003407363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MISG003407OtherBCBS
MI970015187Medicare PIN
MISG003407OtherBCBS
MI0M92460028Medicare PIN