Healthcare Provider Details

I. General information

NPI: 1457333502
Provider Name (Legal Business Name): COREY GALLUS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 03/18/2021
Certification Date: 02/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1808 BRISTOW DRIVE
UNION KY
41091-3513
US

IV. Provider business mailing address

2300 CHAMBER CENTER DR SUITE 200
LAKESIDE PARK KY
41017-1673
US

V. Phone/Fax

Practice location:
  • Phone: 859-301-7210
  • Fax: 859-301-7216
Mailing address:
  • Phone: 859-344-5555
  • Fax: 859-301-7216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number02553
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: