Provider Demographics
NPI:1427056225
Name:GALLIVAN, KATHLEEN HOLLY (MD,MPH,FACS)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:HOLLY
Last Name:GALLIVAN
Suffix:
Gender:F
Credentials:MD,MPH,FACS
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:HOLLY
Other - Last Name:DORR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD, MPH, FACS
Mailing Address - Street 1:100 TRADECENTER
Mailing Address - Street 2:SUITE 750
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-1851
Mailing Address - Country:US
Mailing Address - Phone:781-937-3001
Mailing Address - Fax:781-305-2779
Practice Address - Street 1:100 TRADECENTER
Practice Address - Street 2:SUITE 750
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-1851
Practice Address - Country:US
Practice Address - Phone:781-937-3001
Practice Address - Fax:781-305-2779
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA204711207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0109100Medicaid
MAM12237Medicare ID - Type UnspecifiedGROUP PROVIDER ID
MAA31349Medicare PIN