Provider Demographics
NPI:1972973238
Name:GALLAGHER, CODY (PT)
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:GALLAGHER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 W EXCHANGE ST
Mailing Address - Street 2:PO BOX 268
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-4008
Mailing Address - Country:US
Mailing Address - Phone:815-599-7950
Mailing Address - Fax:
Practice Address - Street 1:1010 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-6600
Practice Address - Country:US
Practice Address - Phone:815-599-7880
Practice Address - Fax:815-599-7238
Is Sole Proprietor?:No
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070021795208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation