Healthcare Provider Details

I. General information

NPI: 1033439302
Provider Name (Legal Business Name): SHALENA THERESE GALLAGHER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2010
Last Update Date: 06/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 W 10TH ST M200-1ST FLOOR
INDIANAPOLIS IN
46202-2859
US

IV. Provider business mailing address

5139 WINTHROP AVE
INDIANAPOLIS IN
46205-1147
US

V. Phone/Fax

Practice location:
  • Phone: 317-656-4260
  • Fax:
Mailing address:
  • Phone: 562-292-9477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number11015502A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: