Healthcare Provider Details

I. General information

NPI: 1336474055
Provider Name (Legal Business Name): KENNETH D. GALEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2009
Last Update Date: 09/23/2022
Certification Date: 09/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2085 RUSTIN AVE STE 1
RIVERSIDE CA
92507-2498
US

IV. Provider business mailing address

1000 SILVER ST.
MIDDLETOWN CT
06489
US

V. Phone/Fax

Practice location:
  • Phone: 951-955-7320
  • Fax:
Mailing address:
  • Phone: 860-262-6512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License Number037287
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: