1972569333 NPI number — SUSAN GALVIN M.D.

Table of content: SUSAN GALVIN M.D. (NPI 1972569333)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972569333 NPI number — SUSAN GALVIN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GALVIN
Provider First Name:
SUSAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COSTA
Provider Other First Name:
SUSAN
Provider Other Middle Name:
CATHERINE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1972569333
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/09/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 15645
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89114-5645
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-560-2900
Provider Business Mailing Address Fax Number:
702-560-2928

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4040 N MARTIN LUTHER KING BLVD
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
NORTH LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-644-4673
Provider Business Practice Location Address Fax Number:
702-902-5443
Provider Enumeration Date:
04/25/2006

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: 207Q00000X , with the licence number:  14531 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1972569333 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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