Healthcare Provider Details

I. General information

NPI: 1992087506
Provider Name (Legal Business Name): GARY C GAILIUS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2011
Last Update Date: 07/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19389 N 59TH AVE
GLENDALE AZ
85308-6500
US

IV. Provider business mailing address

22020 N 30TH DR
PHOENIX AZ
85027-1705
US

V. Phone/Fax

Practice location:
  • Phone: 623-537-6000
  • Fax:
Mailing address:
  • Phone: 858-405-7311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number005941
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: