Healthcare Provider Details

I. General information

NPI: 1043731334
Provider Name (Legal Business Name): SHANNON K GALLAGHER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2017
Last Update Date: 08/17/2023
Certification Date: 08/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W HARRISON ST STE 10
CHICAGO IL
60612-3849
US

IV. Provider business mailing address

1725 W HARRISON ST STE 10
CHICAGO IL
60612-3849
US

V. Phone/Fax

Practice location:
  • Phone: 312-563-3700
  • Fax: 312-563-3701
Mailing address:
  • Phone: 312-563-3700
  • Fax: 312-563-3701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036166466
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number036166466
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: