Provider Demographics
NPI:1962526806
Name:GALLERIA MEDICAL CLINIC, INC.
Entity type:Organization
Organization Name:GALLERIA MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:
Authorized Official - First Name:IRINEO
Authorized Official - Middle Name:D
Authorized Official - Last Name:TIANGCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-479-0320
Mailing Address - Street 1:2340 E 8TH ST
Mailing Address - Street 2:SUITE J
Mailing Address - City:NATIONAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91950-2869
Mailing Address - Country:US
Mailing Address - Phone:619-479-0320
Mailing Address - Fax:619-479-0367
Practice Address - Street 1:2340 E 8TH ST
Practice Address - Street 2:SUITE J
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-2869
Practice Address - Country:US
Practice Address - Phone:619-479-0320
Practice Address - Fax:619-479-0367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-17
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52655207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA52655OtherMEDICARE PTAN