Healthcare Provider Details

I. General information

NPI: 1356443477
Provider Name (Legal Business Name): JOHN KILGALLIN M.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 03/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 DOWELL RD
RUSSELL SPRINGS KY
42642-4278
US

IV. Provider business mailing address

124 DOWELL RD
RUSSELL SPRINGS KY
42642-4278
US

V. Phone/Fax

Practice location:
  • Phone: 270-866-3161
  • Fax: 270-866-3163
Mailing address:
  • Phone: 270-866-3161
  • Fax: 270-866-3163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25723
License Number StateKY

VIII. Authorized Official

Name: JOHN KILGALLIN
Title or Position: OWNER
Credential: M.D.
Phone: 270-866-3161