1104807189 NPI number — MS. HEIDI ANN GALLO ARNP

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 1104807189 NPI number — MS. HEIDI ANN GALLO ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GALLO
Provider First Name:
HEIDI
Provider Middle Name:
ANN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
ARNP
Provider Gender Code:
F

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:
1104807189
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/11/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
908 DUPONT RD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40207-4602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-883-3147
Provider Business Mailing Address Fax Number:
502-891-0028

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
908 DUPONT RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40207-4602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-883-3147
Provider Business Practice Location Address Fax Number:
502-891-0028
Provider Enumeration Date:
11/08/2005

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: 363LA2200X , with the licence number:  3421P , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: K075320 . This is a "MEDICARE PTAN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000000187104 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1161890 . This is a "PASSPORT" identifier . This identifiers is of the category "OTHER".
  • Identifier: 021102300 . This is a "FEDERAL BLACK LUNG" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2439614000 . This is a "PASSPORT ADVANTAGE" identifier . This identifiers is of the category "OTHER".




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