Healthcare Provider Details

I. General information

NPI: 1588921084
Provider Name (Legal Business Name): MICHAEL GARY WALSH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2012
Last Update Date: 03/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 W 1ST ST
PELLA IA
50219
US

IV. Provider business mailing address

710 W 1ST ST
PELLA IA
50219-1613
US

V. Phone/Fax

Practice location:
  • Phone: 641-629-9222
  • Fax:
Mailing address:
  • Phone: 641-629-9222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number58485
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD-42769
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: