1417466053 NPI number — MRS. BRIDGET DARA GALLACE MSED

Table of content: MRS. BRIDGET DARA GALLACE MSED (NPI 1417466053)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417466053 NPI number — MRS. BRIDGET DARA GALLACE MSED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GALLACE
Provider First Name:
BRIDGET
Provider Middle Name:
DARA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSED
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
AMANN
Provider Other First Name:
BRIDGET
Provider Other Middle Name:
DARA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSED
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1417466053
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8 EAST AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLEN COVE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11542-3917
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-672-9043
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8 EAST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLEN COVE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11542-3917
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-672-9043
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/27/2017

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: 252Y00000X , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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