Healthcare Provider Details

I. General information

NPI: 1629465208
Provider Name (Legal Business Name): NICHOLAS GALLAGHER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2015
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 MEDICAL CENTER PKWY
AUGUSTA ME
04330-8160
US

IV. Provider business mailing address

35 MEDICAL CENTER PKWY
AUGUSTA ME
04330-8160
US

V. Phone/Fax

Practice location:
  • Phone: 207-248-5000
  • Fax: 207-626-1648
Mailing address:
  • Phone: 207-248-5000
  • Fax: 207-626-1648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberDO3075
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberDO00947
License Number StateRI
# 4
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License NumberDO3075
License Number StateME
# 5
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number83039
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: