Healthcare Provider Details

I. General information

NPI: 1528660321
Provider Name (Legal Business Name): DANIEL GALLAGHER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2020
Last Update Date: 09/04/2025
Certification Date: 09/04/2025
Deactivation Date: 07/31/2025
Reactivation Date: 08/15/2025

III. Provider practice location address

5961 N LINCOLN AVE
CHICAGO IL
60659-3758
US

IV. Provider business mailing address

5961 N LINCOLN AVE
CHICAGO IL
60659-3758
US

V. Phone/Fax

Practice location:
  • Phone: 312-702-3923
  • Fax:
Mailing address:
  • Phone: 312-702-3923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085010714
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: