1376634345 NPI number — DR. RICHARD BALLOU GALLAHER JR. PHD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376634345 NPI number — DR. RICHARD BALLOU GALLAHER JR. PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GALLAHER
Provider First Name:
RICHARD
Provider Middle Name:
BALLOU
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376634345
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
513 THAIN ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEWISTON
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83501-4140
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-743-0150
Provider Business Mailing Address Fax Number:
208-743-5358

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
513 THAIN ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEWISTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83501-4140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-743-0150
Provider Business Practice Location Address Fax Number:
208-743-5358
Provider Enumeration Date:
09/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  PSY-202154 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103T00000X , with the licence number: PY00000815 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000010147148 . This is a "REGENCE BLUESHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 041256289 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 550867358 . This is a "GENERAL INSURANCE NUMBER" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: Y0929 . This is a "IDAHO BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 806984800 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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