Healthcare Provider Details

I. General information

NPI: 1427056225
Provider Name (Legal Business Name): KATHLEEN HOLLY GALLIVAN MD,MPH,FACS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHLEEN HOLLY DORR MD, MPH, FACS

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 02/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 TRADECENTER SUITE 750
WOBURN MA
01801-1851
US

IV. Provider business mailing address

100 TRADECENTER SUITE 750
WOBURN MA
01801-1851
US

V. Phone/Fax

Practice location:
  • Phone: 781-937-3001
  • Fax: 781-305-2779
Mailing address:
  • Phone: 781-937-3001
  • Fax: 781-305-2779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number204711
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: